Young Mums Smoking Podcast Episode Critical Commentary

The resource developed is an episode from a podcast series called ‘Young Mums’, targeted at
pregnant teenagers. The series follows the pregnancy journey of three Yorkshire teenagers:
Sophie, Scarlett and Courtney. During each episode, the girls explore their opinions and
experiences on a range of topics, supported by the host, Suzie. The aim of this podcast episode
is to prompt pregnant teenagers (under 20 years) who currently smoke, to access their local
NHS Stop Smoking Service (SSS) and attempt to successfully quit. The target audience will be
able to access the podcast via NHS resources and through social media platforms. The
resource has been developed using a combination of appropriate communication, education
and psychological theories and privileges a bottom-up, dialogical and participatory approach
(Cross et al., 2017). It aims to address the lack of and/or shortcomings of previous attempts to
engage this target group in smoking cessation (Flemming et al., 2012; Hill et al., 2013; Johnson
et al., 2019). This rationale will consider how these theories and principles have been applied in
the development of the podcast.

Tobacco smoking has been described as one of the greatest public health challenges faced by
the UK today (Royal College of Physicians, 2018). Pregnant women are at particularly high-risk
for adverse health outcomes from smoking, causing ill-health to both mother and child
(Appendix 1) (Royal College of Physicians, 2010). Smoking during and after pregnancy is
significantly associated with age and social status, with the poorest and youngest most likely to
smoke (Smoking in Pregnancy Challenge Group, 2018). For example, teenage mothers are
almost six times more likely to smoke during and after pregnancy and less likely to access
support to stop (Hill et al., 2013; Action on Smoking and Health, 2016; Johnson et al., 2019).
Yorkshire has some of the highest rates of teenage pregnancy and smoking at time of delivery
in the UK (Public Health England 2019a; 2019b). Therefore, a concerted effort to address the
specific causes and influences on smoking during this life stage is important (Action on Smoking
and Health, 2016).

Local SSS provide pregnant smokers with the best chance of quitting (West and Papadakis,
2019). Use of this service by pregnant women in Yorkshire is low but those who do, have the
highest quit success rates compared to any region in England (Public Health England, 2019b).
Pregnant teenagers have been recognised as a difficult group to access and support (Hill et al.,
2013). Furthermore, there is a dearth of literature identifying appropriate health promotion
resources that are tailored to this age group and that midwives consider suitable to use
(Flemming et al., 2012; Hill et al., 2013; Johnson et al., 2019). Ergo, it was deemed crucial to
address these shortcomings and develop a resource that prompts pregnant teenagers to quit
smoking using their local SSS.

The health literacy of pregnant teenagers who smoke is likely to be low as they tend to fall
within lower socio-economic groups and have poorer educational attainment (Rowlands et al.,
2015; Public Health England, 2019c). Research suggests that negative smoking cessation
outcomes are associated with poor health literacy (Stewart et al., 2013). As low literacy is a
component of low health literacy, a verbal communication medium was deemed more
appropriate than written to overcome this potential barrier (Chinn, 2011). An analysis of the
Capability, Opportunity and Motivation (COM-B) of smokers identified the need for health
promotion materials to inform them of SSS including what the services offer, their efficacy and
what can be expected from a quitting journey (Kwah et al., 2019). The authors highlighted the
importance of storytelling, using smokers from similar demographic backgrounds to convey
these messages (Kwah et al., 2019). A smoking cessation intervention aimed at pregnant
teenagers also found that this group responded most strongly to vox pop stories of quit attempts
made by their peers (Hill et al., 2013). Given the health literacy needs of the target group and
the recommendations stated above, a podcast was deemed the most appropriate
communication medium to engage pregnant teenagers.

The use of digital communication technologies, particularly in people under 35 years of age, has
risen considerably in recent years (McNamara and Brooks, 2016). Furthermore, the popularity
of podcasts as a communication medium has increased markedly with a growth of 2.7 million
listeners aged 15 and above from 2013 to 2018, of which the highest proportionate increase
was amongst the 15-24 age group (Ofcom, 2018). Stockdale and Coyne (2020) suggest that
teenagers seek information which they feel uncomfortable discussing with others from internet-
based platforms. In addition, podcasts offer the opportunity for self-paced learning which is
preferred by pregnant women (Hill et al., 2013). Naughton et al., (2019) recommend that quit
trigger attempts should be provided throughout pregnancy thus the podcast is amenable to
individual information control preferences (Ko et al., 2014).

O’Sullivan and Carr (2018) identify podcasts as a form of mass media. To avoid common
limitations of such communication mediums (namely their one-way, top down and over-
simplistic message), audience segmentation, interpersonal dialogue and feedback through
social media have been used to aid the diffusion of the message (Lasswell, 1948; Cavil and
Bauman, 2004; Kreuter and McClure, 2004; Southwell and Yzer, 2007). This combination of
strategies allows for Lazarsfeld and Merton’s (1955) three prerequisites for mass
communication effectiveness in invoking behaviour change. Monopolization is achieved using
lay voice to direct discussion and promote smoking cessation services (Lazarsfeld and Merton,
1955; Knapp and Daly, 2011). Canalization and supplementation are achieved through the
exploration of the interpersonal relationships between the teenagers and the facilitator as well
as the use of social media to reinforce the messages and disseminate additional information
and resources (Lazarsfeld and Merton, 1955). By supplementing mass communication
messages with interpersonal strategies, it is argued that this podcast is a form of ‘mass-
personal’ communication, using an effective combined communication strategy to affect
behaviour change (Lazarsfeld and Merton, 1955; O’Sullivan and Carr, 2018; Wakefield et al.
2010).

A feedback loop was created using social media platforms Facebook and Twitter to allow for
reciprocal exchange between the podcast and the audience (Peters, 1994; Cross et al., 2017).
These platforms are the most popular amongst teenagers and therefore the most accessible for
the target audience (Madden et al., 2013). It was important that the podcast listeners were able
to participate and contribute to the discussions as well as suggest future topics, to allow for a
‘two- way’ (Hubley, 2004) and ‘circular’ communication approach (Schramm, 1954). Not only
can listeners feedback and be involved in the podcast discussion, they can also participate in
discussions with non-podcast users in a more interpersonal setting, allowing the message to be
transmitted through indirect channels (Southwell and Yzer, 2007).

The aim of the podcast is to increase self-efficacy (via vicarious experience and social
persuasion (Bandura, 1994)), knowledge about SSS and their efficacy (Kwah et al., 2019), and
to modify the attitudes and beliefs of the women listening. Based on the COM-B analysis
recommendations made by Kwah et al. (2019), to maximise the effectiveness of this podcast, it
was necessary to design the messages using psychological and progressive educational theory
(Ko et al., 2014). The Transtheoretical model (Procheska and DiClemente,1982), dialogue, lay
voice and facilitation using motivational interviewing (Miller and Rollnick, 2012) and ‘wicked’
competencies’ (Knight, 2007) were prioritised alongside opportunities for cognitive and affective
learning (Green et al., 2015).

The dialogical approach of the podcast allowed for the exploration of themes around, and
perceived barriers to quitting smoking. Whilst the women in the podcast are from Yorkshire, it is
expected that their stories will reflect pregnant teenagers in the North of England and/or with
similar socioeconomic profiles, and therefore have a wider cultural reach. The thematic universe
(Freire, 1972) of the women was established via the qualitative information available on
smoking in pregnancy (Appendix 2). In doing this, the narrative of the young women could be
structured to reflect their sociocultural norms, explore the structural determinants of their
smoking behaviour and increase the chance of homophily (Kreuter et al., 2003; Green et al.,
2015; Gould et al., 2017). The women are at different stages of the transtheoretical model of
behaviour change (Appendix 3) (Procheska and DiClemente,1982). This allowed the exploration
of their differing beliefs and emotions (automatic motivational factors), with the intention of
increasing the psychological capability and opportunity of the target audience at varying stages
of the quitting journey via persuasion and modelling (Michie et al., 2011; Kwah et al., 2019).

A teleological, fear-based approach was rejected. Raising anxiety and stress levels in our target
group was not deemed ethical, and such stop smoking campaigns are not effective with lower
socioeconomic groups (Bradley, 2013). This sits within the humanist approach and was felt to
be particularly important given the negative lay views regarding receiving smoking cessation
information from those in authority (Appendix 2). Johnson et al., (2019) also emphasises the
importance of a non-judgmental approach in fostering self-efficacy. To this end, the decision
was made not to have a health professional in the podcast (Kennedy, 2017). Instead, the
facilitator creates a non-authoritarian, non-didactic and non-threatening environment (Aubrey
and Riley, 2019). She uses a motivational interviewing approach, guiding and evoking change in
the women by actively listening and acknowledging that they are knowledgeable, with the
practical wisdom needed to change (Miller and Rollnick, 2012; Cross et al., 2017). This also
enabled the avoidance of a neoliberal victim blaming undertone, which has been shown to be a
barrier between pregnant smokers and health professionals (Kwah et al., 2019; Grant et al.,
2020). Additionally, the facilitator’s empathy and use of wicked competencies (Knight, 2007),
enables a positive relationship between the women in the podcast and amplifies the celebratory
nature of Courtney’s success. This allows for quitting smoking to be framed as a positive act,
and Courtney to be used as a cue to action (external cue), improving the chance of listeners
using SSS for a quit attempt (Rosenstock, 1974; Michie et al., 2011; Cornacchione and Smith,
2012; Grant et al., 2020).

Whilst the resource was initially approached with aspirations of Freirean empowerment (Freire,
1972), the confines of the assignment parameters meant that this was not possible. It could be
argued that this is a reflection of the realities of practice within a neoliberal framework and that
often practical approaches are prioritised over ideological perspectives (Hubley, 2004). The goal
of the resource was thus decided in a paternalistic manner (Tengland, 2016) and assumptions
have been made regarding whether the listeners would view quitting smoking as a priority, and
something that would improve their quality of life (Tengland, 2016). Furthermore, although the
existing qualitative literature was used to represent the three teenager’s voices, ideally actual
teenagers would have participated.

To conclude, it is argued that the combination of the communication medium, educational and
psychological theories ameliorates common pitfalls in behaviour change resources such as top-
down, expert-led messages and allows for the exploration of both the external and individual
factors that influence smoking behaviours. The premise of the podcast fits within a personal
empowerment model of health education (Green, 2008) and aims to improve the functional
health literacy (Nutbeam, 2000) of the listeners in a way that increases their autonomy
(Tengland, 2016) and chance of success. It is hoped that the podcast can take the role of
facilitator, with dialogue being enabled via the feedback loop, ensuring the listeners are active
participants in their learning (Green et al., 2015).

Word Count: 1,905

Written by:
Lucy Simpson: 33490053
Emily Ogalbe: 77208473
Clair Greenland: 77236534
Amy Deptford: 77222704
References:

Action on Smoking and Health (2016) Smoking: pregnancy [Online], Action on Smoking and
Health. Available from: <https://ash.org.uk/information-and-resources/health-inequalities/health-
inequalities-resources/smoking-in-pregnancy/> [Accessed 3rd June 2020].
Aubrey, K. and Riley, A. (2019) Understanding and using Educational Theories. 2 Ed. London:
nd

Sage Publishing.

Bandura, A. (1994) Self Efficacy. In: V. Ramachaudran (ed.) Encyclopaedia of Human

Behaviour. New York: Academic Press..

Bradley, I. (2013) Ethical considerations on the use of fear in public health campaigns [Online],
New York: Clinical Correlations. Available from:
<https://www.clinicalcorrelations.org/2011/11/23/ethical-considerations-on-the-use-of-fear-in-
public-health-campaigns/ > [Accessed 18th May 2020].

Bull, L., Burke, R., Walsh, S. and Whitehead, E. (2007) Social attitudes towards smoking in
pregnancy in East Surrey: A qualitative study of smokers, former smokers and non-smokers.
Journal of Neonatal Nursing, 13, pp. 100-106.

Cavill, N. and Bauman, A. (2004) Changing the way people think about health enhancing
physical activity: Do mass media campaigns have a role? Journal of Sports Sciences, 22 (8),
pp. 771–790.

Chinn, D. (2011) Critical health literacy: A review and critical analysis. Social Science and
Medicine, 73, pp. 60-67.

Cornacchione, J. and Smith, S. (2012) The effects of message framing within the stages of
change on smoking cessation intentions and behaviours. Health Communication, 27 (6), pp.
612-22.

Cross, R., Davies, S. and O’Neil, I. (2017) Health Communication: Theoretical and Critical
Perspectives. Cambridge: Policy Press.

Department of Health (2017) Towards a smokefree generation: a tobacco control plan for
England [Online], London: Department of Health. Available from:
<https://www.gov.uk/government/publications/towards-a-smoke-free-generation-tobacco-
control-plan-for-england> [Accessed 3rd June 2020].

Flemming, K., Graham. H., Heirs, M., Fox, D. and Sowden, A. (2012) Smoking in pregnancy: a
systematic review of qualitative research of women who commence pregnancy as smokers.
Journal of Advanced Nursing, 69 (5) December, pp. 1023-1036.

Freire P. (1972) Education: domestication or liberation? Prospect, 11 (2), pp. 18-21.

Gould, G., Bar-Zeev, Y., Bovill, M., Atkins, L., Gruppetta, M., Clarke, M. and Bonevski, B. (2017)
Designing an implementation intervention with the Behaviour Change Wheel for health provider
smoking cessation care for Australian Indigenous pregnant women. Implementation Science,12
(1), pp. 1–14.

Grant, A., Morgan, M., Gallagher, D. and Mannay, D. (2020) Smoking during pregnancy, stigma
and secrets: Visual methods exploration in the UK. Women and Birth, 33, pp. 70-76.

Green, J. (2008) Health education – the case for rehabilitation. Critical Public Health, 18 (4), pp.
447-456.

Green, J., Tones, K., Cross, R. and Woodhall, J. (2015) Health Promotion Planning and
Strategies. 3 ed. London: Sage.
rd

Hill, S., Young, D., Briley, S., Carter, J. and Lang, R. (2013) Baby be smoke free: Teenage
smoking cessation pilot. British Journal of Midwifery, 21 (7) July, pp. 485-491.

Hubley, J. (2004) Communicating Health: An Action Guide to Health Education and Health
Promotion. 2 ed. Oxford: Macmillan Education.
nd

Johnson, F., Hewitt-Taylor, J. and Norton, E. (2019) Lived experiences of young pregnant
women who smoke. British Journal of Midwifery, 27 (7) July, pp. 427-433.

Kennedy, J. (2017) Barriers to success: smoking cessation conversations. British Journal of

Midwifery, 25 (8), pp. 498–504

Knapp, M. and Daly, J. (2011) The SAGE Handbook of Interpersonal Communication. 4th ed.
Thousand Oaks: SAGE publications.

Knight, P. (2007) Fostering and Assessing Wicked Competences. [Online], Available from:
http://www.open.ac.uk/opencetl/resources/pbpl-resources/knight-2007-fostering-and-assessing-
wicked-competencies [accessed 3rd June 2020]

Ko, L., Turner-McGrievy, G. and Campbell, M. (2014) Information Processing Versus Social
Cognitive Mediators of Weight Loss in a Podcast-Delivered Health Intervention. Health
Education & Behavior, 41 (2), pp. 197- 206.

Kreuter, M. and McClure, S. (2004) The role of culture in health communication. Annual Review
of Public Health, 25, pp. 439-55.

Kreuter, M., Lukwago, S., Bucholtz, D., Clark, E. and Sanders-Thompson, V. (2003) Achieving
Cultural Appropriateness in Health Promotion Programs: Targeted and Tailored Approaches.
Health Education & Behavior, 30 (2), pp.133-146.
Kwah, K., Fulton, E. and Brown, K. (2019) Accessing National Health Service Stop Smoking
Services in the UK: a COM-B analysis of barriers and facilitators perceived by smokers, ex-
smokers and stop smoking advisors. Public Health, 171, pp. 123-130.

Lasswell, H. (1948) The structure and function of communication in society. Quoted in: McQuail,
D. and Windahl, S. (1993) Communication Models: For the Study of Mass Communication. 2 nd

ed. London: Routledge..

Lazarsfeld, P. and Merton, R. K. (1955) Mass Communication, popular taste and organised
social action. In Schramm, W (ed) Mass communication. Urbana: University of Illinois Press.

Madden, M., Lenhart, A. and Cortesi, S. (2013) Teens, Social Media, and Privacy. Pew
Research Center, 21 (16), pp. 2-86.

McNamara, S. and Brooks, C. (2016) Promoting Physical Education through Podcasts. Journal
of Physical Education, Recreation & Dance, 87 (6) July, pp. 50-52.

Michie, S., van Stralen, M. and West, R. (2011) The behaviour change wheel: A new method for
characterising and designing behaviour change interventions. Implementation Science, 6 (42),
pp. 1-11

Miller, W. and Rollnick, S. (2012) Motivational interviewing: helping people change. 3rd ed
[Online], New York: Guilford Press. Available From:
<http://search.ebscohost.com.ezproxy.leedsbeckett.ac.uk/login.aspx?
direct=true&db=cat00621a&AN=leeds.745688&site=eds-live&scope=site> [Accessed 1 June
2020].

Naughton, F., Vaz, L., Coleman, T., Orton, S., Bowker, K., Leonardi-Bee J., Cooper, S.,
Vanderbloemen, L., Sutton, S. and Ussher, M. (2019) Interest in and Use of Smoking Cessation
Support Across Pregnancy and Postpartum. Nicotine & Tobacco Research. August, pp. 1-9

Nutbeam, D. (2000) Health Literacy as a public health goal: a challenge for contemporary health
education and communication strategies into the 21st century. Health Promotion International,
15 (3), pp. 259-67

O’Sullivan, P. and Carr, C. (2018) Masspersonal communication: A model bridging the mass-
interpersonal divide. New Media and Society, 20 (3), pp. 1161-1180.

Ofcom (2018) Podcast listening booms in the UK [Online], Ofcom. Available from:
<https://www.ofcom.org.uk/about-ofcom/latest/media/media-releases/2018/uk-podcast-listening-
booms#1> [accessed 18 May 2020].

Peters, J. D. (1994) The gaps of which communication is made. Critical Studies in Media
Communication, 11, pp. 117–140.
Procheska.J. and Di Clemente, C. (1982) Transtheoretical Therapy: Toward a more Integrative
Model of Change. Psychotherapy: Theory, Research and Practice, 19 (3), pp. 276-288

Public Health England (2019a) Child and maternal health profiles: teenage pregnancies and
young parents 2018-19 [Dataset] [Online], Public Health England. Available from:
<https://fingertips.phe.org.uk/profile/child-health-profiles/data#page/13/gid/1938133228/pat/15/
par/E92000001/ati/6/are/E12000003/cid/4> [Accessed 3rd June 2020].

Public Health England (2019b) Local tobacco control profiles: smoking status at time of deliver
2018-19. [Dataset] [Online], Public Health Engand. Available from:
<https://fingertips.phe.org.uk/profile/tobacco-control/data#page/0/gid/1938132885/pat/15/par/
E92000001/ati/6/are/E12000003/cid/4/page-options/ovw-do-0> [Accessed 3rd June 2020].

Public Health England (2019c) Child and maternal health profiles: teenage pregnancies and
young parents 2018-19 [Online], Public Health England. Available from:
<https://fingertips.phe.org.uk/profile/child-health-profiles/data#page/13/gid/1938133228/pat/15/
par/E92000001/ati/6/are/E12000003/cid/4/page-options/ovw-do-0> [Accessed 3rd June 2020].

Rosenstock, I. (1974) Historical origins of the health belief model. Health Education
Monographs, 2, pp. 328–335.

Royal College of Physicians (2010) Passive smoking and children [Online], London: Royal
College of Physicians. Available from: <https://shop.rcplondon.ac.uk/products/passive-smoking-
and-children?variant=663490547> [Accessed 3rd June 2020].

Royal College of Physicians (2018) Hiding in plain sight: Treating tobacco dependency in the
NHS [Online], London: Royal College of Physicians. Available from:
<https://www.rcplondon.ac.uk/projects/outputs/hiding-plain-sight-treating-tobacco-dependency-
nhs> [Accessed 3rd June 2020].

Rowlands, G., Protheroe, J., Winkley, J., Richardson, M., Seed, P., and Rudd, R. (2015) A
mismatch between population health literacy and the complexity of health information: an
observational study. British Journal of General Practice, 65 (635) June, pp. 379–386.

Schramm, W. (1954) How communication works, In: McQuail , D. and Windahl, S. (eds) (1993)
Communication models: For Study of Mass Communication. 2 ed. London. Longman.
nd

Smoking in Pregnancy Challenge Group (2018) Review of the Challenge 2018 [Online], Action
on Smoking and Health. Available from: <https://ash.org.uk/information-and-resources/reports-
submissions/reports/smoking-in-pregnancy-challenge-group-review-of-the-challenge-2018/>
[Accessed 3rd June 2020].

Southwell, B. and Yzer, M. (2007) The roles of interpersonal communication in mass media
campaigns. Communication Yearbook, 31 (1) May, pp. 420-462.
Stewart, D., Adams, C., Cano, M., Correa-Fernández, V., Yisheng, L., Waters, A.J., Wetter, D.
and Vidrine, J. (2013) Associations Between Health Literacy and Established Predictors of
Smoking Cessation. American Journal of Public Health, 103 (7), pp. 43-49.

Stockdale, L. and Coyne, S. (2020) Bored and online: Reasons for using social media,
problematic social networking site use, and behavioral outcomes across the transition from
adolescence to emerging adulthood. Journal of Adolescence, 79 February, pp. 173-183.

Tengland, P. (2016) Behaviour change or empowerment: On the ethics of health-promotion

goals. Health Care Analysis, 24, pp. 24-46.

Tod, A. (2003) Barriers to smoking cessation in pregnancy: a qualitative study. British Journal of
Community Nursing, 8 (2), pp. 56-64

Wakefield, M., Loken, B. and Hornik, R. (2010) Use of mass media campaigns to change health
behaviour. Lancet. 376 (9748) October, pp. 1261-1271.

West, R. and Papadakis, S. (2019) Stop smoking services: increased chances of quitting
[Online], National Centre for Smoking Cessation and Training. Available from:
<https://www.ncsct.co.uk/usr/pub/Stop%20smoking%20services%20effectiveness.pdf>
[Accessed 3rd June 2020].

Appendix 1. Summary of health outcomes for mother and child due to tobacco smoking
Reducing tobacco smoking rates has been deemed by the Royal College of Physicians (2018,
p.6) as the ‘highest priority for health services and health policy’. It is the leading cause of
preventable, premature mortality and morbidity as well as the largest single cause of health
inequalities (Action on Smoking and Health, 2016; Department of Health, 2017; Royal College
of Physicians, 2018). Maternal smoking is linked to 2,200 premature births, 19,000 low birth
weight babies and 5,000 miscarriages a year (Royal College of Physicians, 2010). Moreover,
children born to parents who smoke are two to three times more likely to smoke themselves,
exacerbating the cycle of inequality and disadvantage (Action on Smoking and Health, 2016).
Progress in lowering the national prevalence of smoking at time of delivery has stagnated at
10.6% and regional differences persist, with Yorkshire’s prevalence at 14.4% (Public Health
England, 2019b). To reach the Government’s target of 6% by 2022, the current trajectory would
need to almost double (Department of Health, 2017; Smoking in Pregnancy Challenge Group,
2018).

Appendix 2: Themes uncovered from the qualitative research into smoking in pregnancy

In the absence of the opportunity to generate goals from the laity in Freirean manner, it was
necessary to identify the thematic universe of pregnant teenagers from the qualitative literature
surrounding smoking and smoking cessation during pregnancy. These themes were then used
to inform the dialogue of the podcast.

Common themes identified included;

- Pregnant smokers didn’t understand how SSS could help them quit, feeling that they
didn’t require any further information, and had a lack of awareness of what kind of
support would be offered (Hill et al., 2013; Kwah et al., 2019).

- A lack of awareness of how to access SSS or where it was (Kwah et al., 2019).
There were also misconceptions regarding the harm perceptions of NRT and e-
cigarettes as quit aids (Johnson et al., 2019)

- Fear of being judged and stigmatised by peers (Kwah et al., 2019) and SSS staff (Hill
et al., 2013; Johnson et al., 2019).

- Midwives were reported to give advice in a judgmental manner (Tod 2003; Grant et
al., 2020)

- A belief that they should / would be able to quit on their own (Hill et al., 2013; Kwah
et al., 2019; Johnson et al., 2019; Naughton et al., 2019).

- A lack of willpower / self-efficacy (Tod 2003; Johnson et al., 2019)

 - There was some contradiction in how much awareness pregnant smokers had
regarding the risks of smoking. Tod (2003) stated that all participants in their
research were aware of the major risks of smoking. Whereas Hill et al. (2013)
suggested that young pregnant smokers were unaware of the risks to their baby.

- A feeling that Doctors / health professionals are exaggerating the risks of smoking in
pregnancy as the pregnant women have no lived experience of the reported risks
(personally or socially) (Bull et al., 2007; Grant et al., 2020).

- Smoking was viewed as a stress reliever, helping maintain mental health (Bull et al.,
2007; Tod 2003; Johnson et al., 2019).

- Smoking was culturally acceptable, prevalent within their social circle, viewed as
inevitable and defined certain relationships (Tod 2013; Johnson et al., 2019).

Appendix 3: Stages of the young women according to Procheska and DiClemente’s

(1982) ‘Transtheoretical Model of Behaviour Change’.

‘Pre-contemplative’ – Sophie: Sophie did not want to stop smoking as she enjoyed it. She used
smoking as a coping strategy to combat stress and felt that stopping smoking will cause
increased stress, which she did not want for the baby. Sophie was perhaps beginning to
conform to Courtney and Scarlett’s behaviour as at the end of the podcast episode she stated
how she will think about what has been discussed, possibly moving into the contemplation
stage.

‘Maintenance’ – Courtney: Courtney had stopped smoking whilst pregnant, and is not only
recognizing the medical benefits of stopping smoking for herself and her baby, but she is also
feeling better about herself and is feeling proud for stopping.

‘Relapse’ – Scarlett: Scarlett has been through the stages of change and has now moved over
to relapse due to starting smoking again. Scarlett is feeling a level of guilt for starting smoking
again, and by reflecting on why and speaking to her peer who is at the maintenance stage, she
is able to educate herself on alternative ways to stop smoking, moving into the preparation
stage.