Introduction

Smoking during pregnancy is a preventable risk factor associated with maternal and child morbidity and mortality [1]. Pregnancy is considered an ideal opportunity to intervene in and control tobacco consumption among smokers and their families [2]. However, 52.9% of women who smoke daily continue to smoke during pregnancy, and in the absence of intervention, they are likely to continue smoking [3].

Pregnant smokers face many barriers to and few facilitators of smoking cessation. Different variables, such as sociodemographic, relationship, social, smoking-related, pregnancy-related, health and psychological factors, can predict smoking cessation in pregnancy [4]. Partner support, willingness to change smoking habits, and the role of smoking in relationships are important factors. Recent studies have concluded that education to increase awareness and information about smoking during pregnancy are relevant. Moreover, providing access to effective interventions such as referrals to smoking cessation services, routine carbon monoxide screening, behavioral support, and pharmacotherapy could help pregnant women quit smoking [5]. These interventions effectively reduce tobacco consumption in the general population; however, pregnant smokers usually do not actively pursue them [6–8].

Lazarus and Folkman’s model defines the concept of stress by examining the intricate interaction between an individual and his or her environment. This model can be applied to investigate the role of psychological factors in smoking cessation [9]. According to their framework, anxiety levels depend on one’s ability to manage external demands, internal self-evaluations that exceed the individual’s available resources, and the strategies employed to cope with these stressors [10,11].

This conceptual framework is particularly relevant to our study because smoking cessation is widely recognized as a major source of stress. Although the majority of smokers older than 18 years of age express their desire to quit smoking (52% attempt to quit), only 6% successfully quit smoking after 12 months [12]. Previous research has highlighted the critical importance of stress-induced cravings, especially in people with high levels of nicotine dependence, who are at greatest risk of not quitting. Implementing stress coping programs has been shown to significantly improve the likelihood of successfully quitting smoking [13].

Behavioral support is the most effective smoking cessation intervention for pregnant smokers, but only a minority of pregnant smokers access it. Even though pregnant women are often aware of the negative effects of smoking on their fetus and themselves, they face many barriers that make it difficult to quit smoking. It is well known that the psychological and social environment also play important roles [13,14]. Consequently, additional qualitative studies are needed to analyze these barriers to identify strategies to help pregnant women quit smoking.

Digital interventions are accessible support interventions and alternatives to traditional support for smoking cessation. Moreover, digital interventions are preferred by women, as they note the importance of being informed to avoid cravings and continue abstinence [15].

Currently, only a few digital interventions for pregnant smokers have been developed, and little is known about the acceptability and usability of smartphone apps to aid in smoking cessation during pregnancy. In a study that aimed to determine the opinions of pregnant smokers about the use of an application for smoking cessation, it was concluded that this type of intervention could be feasible. The design of the application was considered a very important element, and pregnant women valued that the content was motivating, educational and personalized [16].

In a previous study, our research group addressed the effectiveness of an intervention based on gamification, the Tobbstop app, for reducing the prevalence of tobacco consumption in the young population [17,18]. Furthermore, a pilot study of a randomized controlled trial of pregnant smokers showed that pregnant app users had continuous abstinence until delivery; specifically, the prevalence of continuous abstinence until delivery was 57% in the intervention group versus 14% in the control group (p = 0.001) [19]. Building upon the findings of this pilot study, we intend to conduct a community-based research trial. This trial will be akin to the pilot study but with necessary adjustments to tailor the new Tobbstop app for pregnant women. The research group will conduct a study titled "Effectiveness of an App for Tobacco Cessation in Pregnant Smokers (TOBBGEST): randomized community trial". The Tobbstop app will be based on educational content, smoker support, recreational activities, games, entertainment features, and integrated social networking capabilities. This approach is based on the clinical practice guidelines for smoker support outlined by the Catalan Institute of Health and the Department of Health. The Department of Health is the regional institution responsible for planning health actions. The Catalan Institute of Health is the primary provider of public health services in Catalonia, ensuring healthcare for more than 80% of the population.

The original Tobbstop app was designed for the general public, and the intention was to adapt it to the needs of pregnant women. Considering the results of the study, messages and advice that are considered appropriate will be added, as well as information about the beneficial effects of smoking cessation on maternal, fetal and child health. Additionally, the app will offer audiovisual support in the form of mindfulness sessions and respiratory/muscle relaxation exercises [20].

We aim to determine the overall perceptions of female smokers regarding the facilitators of and barriers to smoking cessation during pregnancy through a qualitative research approach. The results of this new study will allow us to adapt the Tobbstop application to the needs of this population.

Materials and methods

Discussion

The pregnancy and postpartum stages are periods of change and adaptation, during which important physiological changes occur. In addition, these periods are accompanied by worries and fears related to pregnancy, childbirth and motherhood [23].

While many women quit smoking when they become pregnant, many others continue smoking. These women may be conditioned by many factors that make it difficult for them to quit smoking [24]. Evidence has shown that the risk of mental health problems is greater in pregnant smokers than in nonpregnant smokers. Moreover, the occurrence of pandemics and sociodemographic and economic crises could lead to behavioral changes during pregnancy, leading to an increase in smoking prevalence [25,26]. Recent studies have reported that frustration in motherhood and having a partner who smokes are key barriers to achieving smoking abstinence during the postpartum period, while body weight maintenance during pregnancy and breastfeeding are facilitators of smoking abstinence [27]. In view of these factors, we believe that it is necessary to adapt the Tobbstop app based on the feelings and emotions experienced by pregnant women who attempt to quit smoking.

This study will provide information on barriers to and facilitators of the smoking cessation process in pregnant women, which will improve the content of digital interventions considering patient opinions. Moreover, in-depth patient interviews will contribute to a richer understanding of the health needs, lived experiences and barriers to quitting smoking during pregnancy among pregnant women.

Pregnant smokers frequently find themselves ensnared in a detrimental cycle. They turn to smoking as a coping mechanism to cope with stress and mental distress, even though they are aware of the harm it inflicts on both their unborn child and their own health. This leads to a cycle in which smoking exacerbates pregnant women’s feelings of guilt and vulnerability, all while facing societal pressure to quit. Thus, pressure to quit smoking intensifies addictions, suggesting that professionals should adjust their interventions to motivate patients and not stigmatize them [28]. The Tobbstop app was designed to support pregnant smokers during the quitting process but not to judge them.

This study has several limitations. First, there is the possibility of overrepresentation of groups that tend to spend time participating in focus groups, for example, unemployed individuals. Second, participants will be recruited through convenience sampling in a unique setting with geographic and cultural differences. Third, it must be considered that there are different profiles of pregnant women and that some of those selected may not choose a digital intervention to quit smoking. To mitigate these limitations, we will prioritize maximum variability and heterogeneity when selecting the participant sample.

In summary, this study aims to provide new information for adapting smoking cessation interventions for pregnant women and, consequently, for increasing the success of smoking cessation during pregnancy and the postpartum period.

Supporting information

Acknowledgments

We are thankful for the assistance provided by the Primary Health Care Research Institute (IDIAP Jordi Gol) and for their knowledge of qualitative research.