PHRC Phase 1 (2005-2011) projects - Projects related to smoking

A8-10: Using qualitative research to inform interventions to reduce smoking in pregnancy in England: a systematic review of qualitative studies

  • Principal Investigator: Hilary Graham, York

  • Duration: March 2010 - March 2011 (13 months)


Smoking in pregnancy is a socially-patterned risk. Women in disadvantaged circumstances are more likely to smoke prior to pregnancy than women from more advantaged backgrounds; they are also less likely to quit in pregnancy and, among those who quit, more likely to resume smoking after birth.

Tackling inequalities in smoking is central to England’s public health strategy Healthy Lives, Healthy People and to the associated Tobacco Control Plan. Both strategies emphasise the importance of understanding people’s everyday circumstances as a first step in developing and delivering interventions to promote healthy behaviours. While an important part of the evidence base, systematic reviews of interventions are not, however contextual information on smokers’ lives. Systematic reviews of qualitative research can provide the contextual understanding missing in reviews of interventions and are beginning to fill this gap in the evidence base.

Aims, methods and contribution:

This project aimed to seek to improve the evidence base for interventions to reduce smoking in pregnancy. The project’s main aim was to:

  • Undertake a systematic review of qualitative studies to provide evidence on how women’s circumstances and experiences influence their smoking behaviour in pregnancy, including their attempts to quit.

A supplementary question examined whether the contextual factors identified as influencing smoking behaviour were considered in systematic reviews of interventions to reduce smoking in pregnancy.

The synthesis of qualitative research was undertaken using meta-ethnography, a method that systematically maps, compares and condenses findings from different studies and leads to new interpretations. Twenty eight papers reporting on 25 qualitative studies were identified through systematic searching and included in the review. The studies were all conducted in high income countries which, like the UK, all have marked social gradients in cigarette smoking and explored women’s experiences of smoking in pregnancy.

For the supplementary component of the study, systematic reviews of interventions of smoking cessation in relation to pregnancy published from 2005-2011 were identified. For each review any discussion of contextual factors was recorded.

Four dimensions of women’s circumstances and experiences of smoking in pregnancy were highlighted through the qualitative synthesis, each of which has implications for the design and delivery of interventions to support quitting in pregnancy. The dimensions are the role of partners and the broader dynamics of the couple’s relationship in influencing women’s smoking habits; the motivation to quit for pregnancy rather than for good; the prominence of cutting down both as a method of quitting and an alternative to quitting; the tensions women perceive between scientific and everyday concepts of risk.

The analysis of reviews of interventions highlighted that few existing systematic reviews of interventions address issues of context in any detail.

The project contributes to the policy goals outlined in both Healthy Lives, Healthy People and the Tobacco Control plan by providing insight into how women’s circumstances and experiences influence their smoking behaviour in pregnancy, including their attempts to quit .