Qualitative research to effectively communicate adverse outcomes associated with prenatal smoking: Implications for graphical and textual warnings

Only about 50% of female smokers quit when they find out they are pregnant, and fewer smokers quit later in pregnancy. Tailored messages are needed to increase cessation among female smokers. Using the Theory of Reasoned Action conceptual framework, we explored women's knowledge, attitudes, and beliefs about adverse pregnancy outcomes associated with prenatal smoking. We also explored women's perceptions of two graphic warning labels that depicted a birth defect (cleft lip/palate) and a preterm infant. Twelve focus groups were conducted during June and July 2010 in four diverse U.S. cities among non-pregnant female smokers (n=79). Data were analyzed using NVivo 8 software. Participants' mean age was 25 years, and participants' race was 60% white, 28% black, and 12% other. Women's awareness of the associations of low birth weight and premature birth with prenatal smoking was high. There was moderate to low awareness of the associations of miscarriage/stillbirths, Sudden Infant Death Syndrome (SIDS), and cleft lip/palate. Perceived severity of adverse outcomes had the most influence on cessation. Miscarriage, SIDS, and cleft lip/palate were cited as adverse outcomes that would most impact quitting. Most women reported that graphic warning labels appealed to their emotions. Participants preferred photographic warnings over drawings or cartoons. These findings can be used to inform message development to increase cessation and U.S. policy efforts to include graphic warnings on cigarette packages. Further research is needed to evaluate the effect of text and graphic warnings on women's perceptions, behavior, and intent of quitting.