Does use of a carbon monoxide (CO) monitor in pregnancy promote smoking behaviour change? A qualitative exploration using the COM-B framework

Does use of a carbon monoxide (CO) monitor in pregnancy promote smoking behaviour change? 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A qualitative exploration using the COM-B framework Cherise Fletcher, Elizabeth Hoon, Angela Gialamas, Gustaaf Dekker, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6310946/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Smoking in pregnancy has detrimental impacts on maternal and fetal health. The adverse outcomes attributable to smoking however, are reduced if women cease before 20-weeks gestation. Antenatal carbon monoxide (CO) monitoring could provide motivation for smoking behaviour change, but there is limited evidence on pregnant women’s perceptions of this intervention. Methods Women (n = 13) who smoked tobacco during pregnancy were recruited from an Adelaide hospital. They participated in two interviews, 4-weeks apart, using a CO monitor at both. Interviews were audio-recorded, transcribed and thematically analysed using the Theoretical Domains and COM-B frameworks. Results Analysis generated two sub-groups highlighting differing framework components: Decreased CO group (DCO, n = 7) and Increased CO group (ICO, n = 6), as determined by the CO reading at the second interview compared to the first. For both groups, using the CO monitor was understood as an education intervention increasing smoking impact knowledge. The DCO group used this knowledge to increase motivation via intention and goal formation to change smoking behaviour. They reported positive anticipation of repeat monitor use, and increased motivational conditions, reinforcement, optimism and belief about capabilities at the second interview. The ICO group however reported decreased motivation in response to increased knowledge, describing a combination of overwhelming emotional responses and cognitive overload that did not promote behaviour change. Conclusion Consistent CO monitor use may promote smoking decrease through pregnancy for some (only 2 women in the DCO group reported cessation), but not all women, suggesting antenatal CO monitoring should be carefully considered with reference to individual women’s needs and circumstances. Trial Registration Registered with the Australian New Zealand Clinical Trials (ANZCTR) Registry, Trial ID: ACTRN12621000670875 registered on 02 June 2021. Tobacco Smoking Pregnancy Carbon Monoxide Monitoring COM-B Theoretical Domains Framework 1. Background Smoking in pregnancy can have detrimental impacts on maternal 1 and fetal health, and remains a persistent problem in middle to high-income countries ( 2 ). Women who smoke in pregnancy are at greater risk of experiencing pregnancy complications including miscarriage, preterm birth, stillbirth and placental abnormalities ( 3 ). Furthermore, their infants are at greater susceptibility of sudden infant death syndrome (SIDS) ( 4 ) and ongoing medical issues including respiratory dysfunction ( 5 , 6 ), impaired cognitive development ( 7 – 9 ) and behavioural difficulties ( 10 – 12 ). Complications related to smoking can have considerable impact on women and their families, as well as placing strain on an already over-extended maternity healthcare system ( 2 ). Importantly, the adverse outcomes attributable to smoking in pregnancy can be reduced if women cease smoking prior to 20 weeks gestation ( 13 ). In 2022, the Australian Institute of Health and Welfare (AIHW) reported that 8.3% of pregnant women reported tobacco smoking at some point in their pregnancy ( 14 ). However, smoking rates in pregnancy are higher among women living in socioeconomically disadvantaged circumstances ( 14 ). Approximately 16% of women living in the most disadvantaged circumstances in Australia report smoking during pregnancy ( 14 ). It is estimated that only 4% of women who smoke will cease smoking during pregnancy ( 6 ), and it is estimated that this is lower among women who live in disadvantaged circumstances ( 15 ). The South Australian perinatal practice guidelines ( 16 ) currently recommend a brief intervention approach to smoking cessation in pregnancy using the 5A’s (Ask, Advise, Assess, Assist, Ask Again). This typically involves health providers completing a primary assessment at triage (first hospital visit) with women when they present at approximately 15–20 weeks gestation. Health providers will enquire about smoking status, assess nicotine dependence and offer women who smoke a referral to the telephone counselling service Quitline. Other than Quitline, women are unlikely to be offered any other support or advice about cessation by health providers in the hospital service ( 17 , 18 ). Previous work has distinctly indicated that pregnant women are reluctant to engage with Quitline, and generally find the service unhelpful and impractical ( 18 ). Antenatal care provides an important and unique opportunity to address smoking, as women will have close contact with the healthcare system for an extended period. Given the reluctance of women to engage with Quitline, it is essential that alternative smoking cessation methods and motivators are explored and evaluated with pregnant women to determine whether they are understood as beneficial, acceptable and practical. Monitoring carbon monoxide (CO) in expired air provides an opportunity for healthcare providers to discuss smoking and quitting support options with women who smoke during pregnancy ( 19 , 20 ). CO monitoring can be a motivating factor to quit and progress can be mapped with every quit attempt ( 21 ). One Australian pilot study reported that CO readings were the most encouraging factor for cessation, more so than the offer of Nicotine Replacement Therapy (NRT) and a Quitline referral ( 21 ). Other studies have reported that CO monitoring is a potentially cost-effective means of encouraging smoking cessation, resulting in projected future savings for the healthcare system for smoking-related morbidity and mortality ( 22 ). Our previous research has identified that women (unpublished) and midwives are interested in the potential for CO breath testing to facilitate conversations about smoking during pregnancy ( 17 ). A recent systemic review explored CO testing in pregnancy ( 2 ). A total of fifteen studies were included in the review spanning 1983–2020. Universal CO testing with ‘opt-out’ referral pathways, successfully increased referrals to cessation support, however, did not necessarily increase the identification of unreported smoking in pregnancy ( 2 ). Mixed outcomes were observed for smoking cessation. Of the seven studies that specifically reported on smoking cessation, two found improved cessation rates while the remaining five did not ( 2 ). Only four studies in the systematic review explored women’s perceptions of CO testing ( 2 ), with 2 reporting CO testing was acceptable. However, women felt they were not provided clear information regarding the output and this further created strain and distrust within the midwife/woman dyad ( 2 ). Gaudron and Davis (2024) concluded their systemic review stating that “ CO testing in pregnancy is also designed to motivate women to quit smoking, but there is very little evidence that it does so ” ( 2 ). Given the distinct lack of evidence regarding women’s perceptions of CO implementation antenatally, we aim to explore the direct role it can play in smoking behaviour change when comprehensively considered within the Theoretical Domains and COM-B Frameworks. 2. Methods 2.1 Theoretical perspective A critical phenomenological approach was used to understand the lived experiences of women who engage with CO monitoring during antenatal care. This approach describes the meaning of experiences in terms of what was experienced and how it was experienced ( 23 ), considered and informed by the Theoretical Domains Framework, COM-B model and behaviour change wheel ( 24 ). We take a constructionist epistemological position where meaning is understood to arise in and out of our engagement with the realities in our world and is advantageous in generating contextual understanding of a defined topic, for example, understanding how antenatal use of a CO monitor impacts smoking cessation ( 25 ). The behaviour change wheel (BCW) is a model that incorporates multiple behaviour change theories. At the centre of the wheel is the COM-B model ( 26 ). This is an acronym for the conditions capability (C), opportunity (O) and motivation (M), all which drive behaviour change (B) ( 24 ). These conditions integrate the behavioural elements of the Theoretical Domains Framework (TDF) to describe the various facilitators and/or barriers that individuals may encounter as they attempt behaviour change, see Table 1. The COM-B model recognises that all 3 conditions flow in and out of each other to influence behaviour change, and that behavioural elements within each condition, can promote, dissuade or inhibit a desired behaviour change outcome. The BCW and COM-B can therefore be used to analyse a behaviour change intervention and determine if that intervention has a systematic approach to achieve change, and the proposed mechanisms of action ( 27 ). CO monitoring in pregnancy was therefore explored as an intervention function within this framework, and the individual conditional domains were considered as potential barriers and/or facilitators to smoking behaviour change. Table 1 Displays the 3 COM-B conditions and how the behavioural elements of the Theoretical Domains Framework are placed within each category. COM-B Condition Sub-element Theoretical Domains Framework Capability Physical Physical skill Psychological Knowledge Behavioural regulation Memory, attention & decision processes Opportunity Physical Environmental context & resources Social Social influences Motivation Reflective Social role & identity Belief about capabilities Optimism Beliefs about consequences Intentions Automatic Reinforcement Emotion This study was approved by the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (HREC), approval number 2021/HRE00038. All participants provided written informed consent prior to participating. 2.2 Sample and recruitment This research study came from and was endorsed by a Community Reference Group, that was established to promote the overall program of work on smoking cessation in pregnancy for women living in northern Adelaide. Participants for this study included women (n = 13) who smoked tobacco cigarettes during their pregnancy (any gestation) recruited between December 2021 and December 2022. Health professionals (obstetricians and midwives) in the antenatal clinic or Midwifery Group Practice (MGP) at a single metropolitan public hospital in South Australia (SA) conducted a brief eligibility screen of pregnant women who presented for antenatal care. This hospital is located in a region with the lowest quintile Index of Relative Socio-economic Advantage and Disadvantage of the Socio-Economic Indexes for Areas as indicated by the Australian Bureau of Statistics 2016 census data. If a pregnant woman was identified by antenatal clinic staff as currently smoking, they were asked to consent to a conversation with a researcher (CF) about the project. Eligibility was determined if women were over 18 years, could communicate in English without difficulty, and were willing and able to give informed consent for participation. The nature of the study, including what a CO monitor is, and the information that can be obtained from CO breath analysis was discussed. Women who agreed to participate, had contact details obtained and either organised to participate immediately in the antenatal clinic, or at a future convenient timepoint in the clinic or local community centre. If required, women were offered taxi vouchers to attend interviews at a local community centre. 2.3 Data collection and analysis Once consent was obtained, participants completed a questionnaire collecting sociodemographic information. In accordance with ethics approval and maintaining the confidentiality of women, demographic data where n < 5 will not be presented. Given the expiratory nature of using the CO monitor, participants were also asked to complete a Covid-19 rapid antigen test (RAT) (a condition stipulated by the public hospital divisional directors for participation). Participation was dependent on a negative RAT result. Women were then asked to use a calibrated CO monitor (PiCO Baby Smokerlyzer). CO breath analysis involved the participant taking a breath and holding it for 15 seconds, then blowing into a mouthpiece attached to the CO monitor to empty their lungs. CO readings were then displayed on the monitor for both the mother and the fetus. The CO level was explained to the participant with a poster (visual aid) provided by the manufacturer ( 28 ), which showed maternal and fetal CO content of blood. The monitor displays 3 numbers on completion of use: CO on the breath and in the lungs measured in ppm (0–30+), maternal blood carboxyhaemoglobin (%COHb) and fetal blood carboxyhaemoglobin (%fCOHb) which measures the percentage of vital oxygen that has been replaced by CO in the bloodstream ( 28 ). The numbers are colour coded and correlate approximately to the amount a person is smoking (green 0–3 ppm non-smoker, amber 4–6 ppm less than 10 cigarettes/day and red 7–30 + ppm greater than 15 cigarettes/day) ( 28 ). CO readings were documented and the researcher (CF) conducted interviews with participants exploring questions detailed in Supplementary File 1. On completion of the scheduled interview questions, the researcher (CF) discussed and provided information relevant to support women’s mental health, as well as specific information related to smoking cessation, including NRT, Quitline, counselling and smart phone applications. This material can be found in Supplementary File 2 (Smoking cessation and support resource). Using the monitor, interview and discussing the smoking cessation support information was audio recorded with the participant’s consent. Interviews ranged in length from 15 to 50 minutes. Participants were also provided with a template letter to share with their general practitioner (GP) should they wish to access additional support. Two to three days after CO monitor use and interview, participants received a welfare check via phone call or text from CF. This welfare check was to determine if they wanted assistance obtaining additional support. Approximately 4 weeks after the initial interview, women were contacted to establish a follow up interview (if smoking cessation was attempted, this is a reasonable length of time for behavioural changes to be established). This was either organised at the hospital at the participant’s next antenatal appointment or at a local community centre with the same researcher who had conducted the first interview (CF). Taxi vouchers were offered if meeting in a community space. Women completed a Covid-19 RAT, used the CO monitor for a second time and participated in another interview. Interview schedule for the second interview is detailed in Supplementary File 1. Again, using the monitor and the interview were audio recorded with the participant’s consent. Interviews ranged in length from 10 to 31 minutes. After completing the second interview, women were provided with a $ 50 gift card for their participation in the study. Women were free to withdraw from the study at any time, for any reason. Reflective discussions with the wider team (CF, EH, AG and LS) allowed debriefing on key learnings from interviews. The interviews (n = 25) were transcribed by CI Fletcher or a transcriber who had signed a confidentiality agreement with the University. Transcripts were assessed against the original recording and reviewed. Participants were categorised into two groups, ‘Decreased CO’ or ‘Increased CO’, determined by whether their CO (ppm) at second interview was less than, or greater than their CO (ppm) at first interview. Data was coded and thematically analysed as described by Clarke and Braun ( 29 ). Data was coded deductively,. Data analysis was predominantly conducted by a single researcher (CF). Ongoing discussions with an experienced qualitative researcher (EH) allowed for a collaborative discussion of the applied coding framework. NVivo 12 qualitative software (QSR International) was used for coding and managing data. 3. Results 3.1 Demographic characteristics A total of 13 participants were included in the study. Twelve participants completed both a first and second interview, with one participant lost to follow up and only completing a first interview. Characteristics of participants collected at the time of enrolment in the study are detailed in Table 2. All identified as women, were pregnant at inclusion of the trial with a mean gestation of 23 weeks (range 15–32 weeks) and self-reported tobacco cigarette smoking in pregnancy. All women resided in areas with the lowest quintile Index of Relative Socio-economic Disadvantage (IRSD). This was reflected by over 65% of participants holding an Australian Healthcare card, where the Australian government sets eligibility at a weekly household income below $ AUD 1,130. Table 2 Socio-demographic characteristics of study participants (n = 13) Characteristic Mean (range) N (%) Age (years) 28 ( 19 – 36 ) 13 Age started smoking (years) 15 ( 13 – 19 ) 13 Weeks gestation at enrolment in trial (range) 23 ( 15 – 32 ) 13 Gravida 1–4 7 (54) 5+ 6 ( 46 ) Parity 0–1 5 ( 38 ) 2–3 8 (62) Education Did not complete high school 7 (54) Completed high school or vocational training 6 ( 46 ) Employment Carer/home duties or unemployed 8 (62) Part-time or casual paid employment 5 ( 38 ) Living with other people who smoke Yes 6 ( 46 ) No 7 (54) 3.2 CO readings for participants Table 3 displays the mean CO readings for participants by group at their first and second interviews. Seven women (including those that quit) demonstrated a decreased CO (ppm) reading at their second interview compared with their first (Decreased CO - DCO) and 6 women had CO (ppm) readings at second interview that were higher than their first (Increased CO - ICO). It was assumed that the participant lost to follow up at interview 2 had made minimal changes to their smoking behaviour and was thus included in the Increased CO group. This is consistent with the Russell standard that assumes non-attendance at subsequent visits indicates continued smoking ( 30 ). While researchers aimed to conduct a second interview at 4 weeks from the initial interview, the average time between interviews was 6 weeks. This was primarily due to scheduling issues. All readings at the first interview confirmed women were currently smoking. The majority of participants (~ 77%, n = 10) at first interview had a CO (ppm) greater than 9 (in red zone) indicating they were moderate to heavy smokers (~ 20 + cigarettes/day). Three women at the first interview received readings in the amber zone indicating light smoking (~ 10 or less cigarettes/day). Two of these women were successful at smoking cessation at follow up as indicated by CO (ppm) readings in the green zone. At second interview, the majority of participants (75%, n = 9), had a CO (ppm) greater than 7 (red zone) indicating that they remained moderate to heavy smokers. Table 3 Mean CO (ppm) readings at each interview by group Group Mean Interview 1 CO (ppm) Range N (%) Mean Interview 2 CO (ppm) Range N (%) Decreased CO 13.1 4–28 7 (54) 10.6 2–25 7 (58) Increased CO 16.0 5–30 6 ( 46 ) 20.6 6–31 5 ( 42 )* *Participant lost to follow-up (LTF) 3.2 Qualitative analysis Qualitative analysis of the interview data identified differences across the COM-B conditions and subsequent TDF behavioural elements depending on the group. Women in the Decreased CO (DCO) group were more likely to have attempted cessation several times in the past and therefore appreciated that quitting was an ongoing journey and process. As they had attempted quitting in the past, they had some experience and/or knowledge of techniques to disrupt habit formation, vaping, NRT and social supports considered beneficial for supporting behaviour change. Both groups demonstrated an increased capability when the CO monitor was used as an education intervention to increase the knowledge/understanding of the impact of smoking (3.2.1). Following this knowledge increase, the DCO group were subsequently able to increase their motivational condition by forming intention and goals (behavioural elements) to change smoking behaviour (3.2.2). The Increased CO (ICO) group however, in response to the increased knowledge, exhibited decreased motivation with an emotional spiral and successive cognitive overload (3.2.3) that was not conducive to behaviour change. For the DCO group, having formed specific intentions and goals that translated to small changes in behaviour, participants reported positive anticipation in knowing they would use the monitor again at a second interview. For this group there were further increases in the motivational condition with increases in reinforcement, optimism and belief about capabilities (3.2.4). The ICO group did not experience the same positive anticipation and reinforcement with repeat monitor use. However, they saw the value the CO monitor could provide if it were to be used in routine antenatal care (3.2.4). Finally, both groups revealed substantial barriers within the opportunity condition (social influences and environmental context/resources) and physical skills within the capability condition, irrespective of monitor use, that limited successful behavioural change (3.2.5). 3.2.1 Increased capability : Knowledge increased as an education intervention When the CO monitor was used at the first interview with participants (both groups), it served as an education intervention function. That is, its use aimed to increase knowledge and understanding of the impact smoking can have on maternal and fetal health. Participants were initially unclear on how the CO reading was a proxy for smoking. However, once this was discussed with the researcher, women had a deeper understanding of smoking impact on monitor output. ‘No one ever really mentioned the carbon monoxide, just that smoking’s bad.’ P11 DCO ‘It does sort of like make sense that umm, I suppose as to how many cigarettes I do smoke as yeah, as to how much carbon monoxide would be in my blood.’ P1 ICO The zone colours (green, amber, red) and scale evident on the detailed manufacturer’s maternity chart provided clear information that was understood by participants. ‘Like it puts a little bit of more of a shock factor into it, seeing the colours. I, I’d probably like the more information because each coloured section gives you an idea of like the green, you know…light to non-smoker for orange, and then, yeah.’ P12 DCO Women acknowledged the importance of the information obtained from the CO monitor and felt that it was essential for any women who was smoking in pregnancy to understand. ‘…These are the things that you should, you know, pay attention too, of how much it's actually…taking into your baby and how much you don't think is.’ P3 ICO Considering the COM-B conditions, it was evident CO monitor use increased women’s psychological capability by enhancing the knowledge behavioural element. Knowledge from the monitor was then able to have an influence on motivational conditions – belief about consequence (reflective) – and emotion (automatic). For the DCO group, output from the monitor allowed women to validate and accept the truth that smoking is damaging, as well as corroborating their dislike of smoking. ‘…Because, like, I know smoking is bad for unborn babies and I want to change and quit for my child. Like even though if I wasn’t pregnant, I know it’s not good for me, and it’s not making my health any better.’ P4 DCO ‘…Oh my God, like I just hate smoking. Like I don't sit there and go, “Oh my God, I love cigarettes, everyone should smoke”. I think they're the most disgusting thing on the face of the planet. Like, they stink. Your hair's like…stinks!’ P2 DCO Women in the ICO group, however, held a less nuanced view of the damaging impact of smoking. They were therefore surprised by the CO reading and this subsequently affected their belief of consequence. ‘Well, I thought it [unclear] not so bad but still in orange but no, in red. That’s terrible. Yeah, that’s not great.’ P5 ICO ‘…But it does – it is a bit of an eye opener, that’s all, yeah, to see actually how much yeah, it does affect.’ P6 ICO Both groups expressed strong emotion when using the monitor. Most women found the monitor use confronting and described feeling disappointment, guilt and/or shame for smoking in pregnancy. The participants however felt that feeling guilty could be a motivator for change, and participants in the DCO group also felt gratitude at gaining greater knowledge about the impact of smoking. ‘I think you can guilt a lot of parents to quitting because I feel quite guilty seeing how high it is and I haven't had a smoke for ages…’ P3 ICO ‘Um. Yeah. It’s just putting a number on it, like it’s kind of a bit confronting when you look at the graph…Ah, it’s a bit hard. It sucks.’ P11 DCO ‘Thank you for making me aware of it. That’s good.’ P8 DCO For both groups, the guilt and/or shame felt from using the monitor was a reflection on how they perceived their social role and identity. Women wanted to identify as ‘good mothers’ who care responsibly for their developing baby. In fact, most women who participated in this trial expressed that they had decreased smoking on learning of their pregnancy. This was in an attempt to develop a more responsible maternal identity. However, women’s perception of their social role and identity, and their emotional reactions to using the monitor, had different impacts on behavioural elements within the COM-B model for the DCO group vs the ICO group. This will be explored separately in sections 3.2.2 and 3.2.3. 3.2.2 Increased motivation : Women developing intent and goals for behaviour change (DCO group) Although women in the DCO group expressed feelings of guilt, and found the monitor use confronting, their mindset at the time of first monitor use meant that they formed specific intentions and goals with resolve to either quit smoking (n = 2) or reduce the number of cigarettes they were smoking on a daily basis (n = 5). ‘But I have been focusing a lot, a lot more of what I can do to quit, at least looking at it in the future and not just going ohh, I'll think about it later, and it's…been on my mind very frequently too, like everyday…’ P2 DCO ‘…It’ll just make me think about it every time I have a cigarette now [CO monitor reading].’ P8 DCO This was driven by their social role and identity to be ‘responsible mothers’, their feeling of gratitude for the additional knowledge of the impact smoking had on health, as well as expressed excitement and optimism that the CO monitor could be used as an indicator of behaviour change. ‘…So if someone’s trying to quit smoking and had a monitor like that that they could like monitor their levels and watch it [going] down might be a bit of a reward kind of thing, like, oh wow, like me not smoking 20 a day has made it go down to this and like the more I quit the lower it goes.’ P11 DCO Considering the transtheoretical model of behaviour change, women in the DCO group were more likely to be in the contemplation, preparation or action phases of the model and therefore use knowledge of the monitor to change behaviour. ‘ Participant : I guess [unclear] a different with other people, you know, with the certain ways that they want to go ahead with it. Like I guess with me, because I want to quit…it's just a good motivation for me. Researcher : So, do you feel if someone is in that frame of mind where they do want to make changes, that it could be really positive? Participant : Mm-hm. Yep.’ P7 DCO Women in this group were further aware that stress and anxiety due to poor mental health were significant barriers to changing smoking behaviour. Women described intent and determination with accessing mental health supports to better manage these feelings so that they had less impact on smoking behaviour. ‘I currently see the perinatal mental health here. I have constant contact with a mental health nurse here. I also see a counsellor through Relationships Australia. And I’m in the process of getting back with my psychologist.’ P12 DCO ‘But it definitely helped with the anxiety side [NRT and GP assistance], which is what I really struggle with trying to quit.’ P11 DCO Women in this group developed additional intentions to reduce the CO monitor reading at follow up by also actively removing themselves from others who were smoking. Thus, reducing the impact passive smoking would have on a future CO reading. ‘Researcher : …Is that something that’s changed…like not being around him as much when he’s having a cigarette? Participant : Yeah. I just tell him to go have a cigarette. I don’t – or I’ll roll it and I won’t roll myself one…’ P8 DCO With their intentions established, women were then able to generate constructive goals for changing smoking behaviour specifically related to the CO monitor. These included aiming to reduce the CO ppm at the next interview, not have it increase, or to reduce the colour zone at the next interview. ‘Definitely. I think it was – it did have an impact seeing the number so high it kind of made me like, oh, I want to get it lower...’ P11 DCO ‘Kind of go down to the green now.’ P7 DCO The goals developed by the DCO group participants were then able to affect their decision processes and behavioural regulation capabilities. At interview 2, women retained the information from the CO monitor and indicated they ‘thought’ about the ppm number or zone colour, and used this as a deterrent to having a cigarette in the moment. ‘ Researcher : Do you feel like having used the monitor when we did…- did that influence... Participant : Oh, yeah…A little bit, realising how much toxin's in me…So yeah, it helped me push meself a bit more.’ P4 DCO ‘…I just thought – actually, I think it was just a thing I got in my head [CO monitor reading]…’ P8 DCO 3.2.3 Decreased motivation : Emotional spiral & subsequent cognitive overload (ICO group) Women in the ICO group had an overwhelming emotional response to using the CO monitor at the first interview and this impacted several behavioural elements within the COM-B conditions. They described feeling disappointed, shocked, disgusted and ‘feral’ at the impact smoking was having on their baby’s health (not necessarily their own). Women therefore felt forced in this moment to acknowledge and accept the negative implications of smoking. ‘Made me feel like crap, to be honest, that she’s [fetus] getting that much.’ P13 ICO ‘Um, it’s pretty disgusting if it’s up that high. Like yeah, it’s not good…I think more about the baby, yeah, but just, yeah, it’s not cool either way.’ P6 ICO Confronted with this reality and belief about consequence, women’s guilt and shame were amplified. They felt overwhelmed, stressed and anxious, all positive indicators of cognitive overload. Women predominantly reported using smoking as a coping mechanism to manage these feelings, hence the using of the monitor made women in the ICO group feel like they wanted a cigarette. ‘ Researcher : Now that you’ve used the monitor, how do you feel about your smoking? Participant : Like I need a cigarette actually.’ P5 ICO ‘ Researcher : …It's now become a coping mechanism for you? Participant : Yeah like I just - I - to go to sleep at night I have to have a couple of ciggies otherwise I sit there and toss and turn all night…so yeah, like, I pretty much rely on it as - it’s like medication to me.’ P8 ICO Women in the ICO group nevertheless expressed a wish to identify as ‘good mothers’ who reduce smoking in pregnancy (social role and identity). Thus, their motivational intention to ‘cut down’ was founded in the abrupt emotional belief of consequence at using the monitor and how they felt a ‘good mother’ should responsibly behave. ‘…I don't umm, I know for myself I should be feeling that, you know, that's still a fair bit for myself but I don't know why, but I don't feel like it, if it was just me, I wouldn't feel…’ P1 ICO ‘…It’s just really opened my eyes to the fact of, that’s how much is actually going through, and she doesn’t need that. She doesn’t – she can’t take that. Gee, that’s a lot, but – yeah, no.’ P13 ICO When women experienced the cognitive overload of using the monitor they felt forced to ‘second guess’ their belief system about the impacts of smoking on fetal health. To manage this emotion they engaged lay epidemiology to self-soothe and refute current medical evidence (Memory, attention and decision processes), rather than believe the monitor output. ‘I think again, only because my baby, like the babies, have been healthy. I don't really think too much about the side effects of what it should do like long term or even that short term when it's growing…’ P3 ICO Prior to using the monitor at the first interview, the majority of women in the ICO group described having reduced the number of cigarettes they were smoking daily. Thus, they firmly believed that this would be reflected on the CO monitor. However, in most cases, the reading was higher than they expected (in the red zone), and this considerably decreased women’s belief in their capabilities and optimism that they could successfully change their smoking behaviour. ‘Umm, like I, I suppose I hadn't felt that bad because I'd I'd really cut back on my smoking. I still didn't feel OK that I was still smoking. But yeah…’ P1 ICO ‘…I probably have to try and cut down a lot more than what I have. But, yeah, that’s harder said than uh done...’ P10 ICO Furthermore, several women in the ICO group were consuming alcohol or illicit drugs during pregnancy. They had been strongly advised by medical professionals to restrict these behaviours and this was the priority, rather than reducing or quitting cigarette smoking. ‘ Participant : Cos, I was umm, like before, I was smoking marijuana, which I'm not anymore…I had a doctor say to me, he was very you know, old-fashioned…And such said to me ‘You know, you shouldn't be doing that’ and… Researcher : So for the doctor was the priority marijuana stopping over tobacco smoking? Participant : Yes, yes.’ P1 ICO Therefore, given that some women were already attempting to change other harmful behaviours, using the CO monitor was additionally overwhelming because they felt they needed smoking as a coping mechanism in the absence of other alcohol and/or drugs. This further decreased their belief in capability and optimism to successfully make changes to smoking behaviour. Already feeling guilt and shame, then experiencing the overwhelming stress, anxiety and confrontation of using the CO monitor, coupled with decreased belief in their capabilities and optimism, women continued to use smoking as a coping mechanism despite monitor use. Interestingly, this eventuation was predicted by the participants in The DCO group. ‘You know, because I think that when you feel guilty about it, it actually makes you smoke more because you're feeling bad about yourself.’ P2 DCO ‘ Researcher : …Your feeling is that giving women too much information…could potentially just turn them off to… Participant : And then make them chain smoke afterwards.’ P8 DCO Despite the overwhelming emotion felt by women in the ICO group and subsequent cognitive overload from CO monitor use, interestingly they deemed feeling guilty a necessary element to prompt or motivate behaviour change. ‘No, well if it makes me feel bad, then obviously it would be helpful to kind of like, if people aren’t feeling bad about what they’re doing then they’re not going to change much, are they, so I guess feeling bad is not a bad thing in a way, because it makes you kind of want to do something more about it.’ P6 ICO ‘It could in like some circumstances but in a way, like without that little bit of guilt, and that little bit of push, you don't get that urge to give up.’ P10 ICO This then potentially places use of the CO monitor antenatally as a persuasion intervention function in addition to an education one. A persuasion intervention function uses communication to induce positive or negative feelings to promote behaviour change. Both groups report feeling emotion in response to using the CO monitor. For the DCO group, the combination of positive and negative emotion, as well as the improvement of other motivational behavioural elements is able to ‘persuade’ behavioural change, albeit limited. However, for the ICO group, experiencing only a negative cascade of emotion, which in turn decreases other motivational behavioural elements, using the monitor is unsuccessful in ‘persuading’ behaviour change. 3.2.4 Increased motivation : Positive reinforcement in repeated CO monitor use Women in the DCO group were further motivated to regulate their smoking behaviour with the anticipation of repeated CO monitor use at the second interview. When their CO reading decreased, this provided positive reinforcement (reward) for changes to behaviour, even if small. Women described feeling pleased/happy, proud and excited that the CO reading decreased. ‘…But, yep, definitely if it was offered, someone like myself would be like, oh cool…I get to use that at my appointment.’ P11 DCO ‘ Participant : Oh. That’s hell good! Yeah. That’s really good. Researcher : Do you think that it’s nice to see that, um, you’ve made a change to your smoking, and it’s had an impact? Participant : Yeah. I can see it as well. When I cough up stuff in the morning, you can see it’s not as – there as much.’ P8 DCO ‘I’m happy with it, that’s for sure…Seeing it a bit lower is definitely good.’ P11 DCO The emotion generated from positive reinforcement further improved women’s optimism and belief in their capabilities, and this was a motivator to continue to modify behaviour during pregnancy and reduce smoking. ‘I think it would be very cool to see, um, especially if you’re a heavy smoker I suppose, um, if you started using it when first started quitting and then seeing it go down, I think would really motivate you to keep quitting.’ P11 DCO ‘But yeah, so, it’s not much but it obviously goes to show that it really does make a difference to cut down.’ P12 DCO For the women in the ICO group however, the anticipation of repeated CO monitor use at interview 2 led to self-reported increases in their stress and anxiety. Women continued to use smoking as a coping mechanism when faced with these feelings. Women acknowledged that they were also fearful of using the monitor because their previous efforts to modify behaviour had not been reflected in the CO reading. Additionally, they felt they had not reflected on the monitor output and therefore had limited behavioural modification. ‘Haven't really considered too much [previous CO reading]…Still, quite high, I remember that chart, fuck that's high.’ P3 ICO Researcher : …That you’ve reflected on over the time? Participant : Yeah. A little bit. Like I thought it was going to affect me a lot more, to be honest…And I’m a little bit gutted that it didn’t…’ P5 ICO While the women in the ICO group showed increased CO readings at the second interview, they acknowledged the value the CO monitor could have as a positive reinforcer for smoking reduction. They also suggested introduction of the CO monitor in early pregnancy for maximum influence. ‘Yeah, like giving them the thought straight away [before 12 weeks gestation], like from the get go, as soon as they find out they're pregnant, especially in the early stages because that's when everyone worries the most.’ P10 ICO Researcher : …You would see the number come down, do you think that that's a positive? Participant : That is. Yeah, yep. No, definitely, if they see a change in it umm they might, you know, that will help them think, ‘well, I am doing something that's working’. P1 ICO As both groups could see value in using the CO monitor as a positive reinforcer, they were receptive to the idea of increased use in routine antenatal care, as well as in local pharmacies for autonomous independent use. ‘I think that it's a good thing [using CO monitor in pregnancy], but I think it's been helpful that I don't feel judged. I think it would really depend on the people who are doing it.’ P2 DCO ‘ Researcher : Do you think using something like this more regularly in antenatal care could be a good thing? Participant : Yeah…It'll help girls realise...how much of it is in their body.’ P4 DCO ‘ Researcher : Do you think that would help with women’s motivation if they…were able to test themselves more often? Participant : Oh yeah. I reckon. Yeah. That’s what I mean. If you see it going down, you’re gonna be like, fuck yeah. Oh sorry.’ P5 ICO Women in both groups did however feel that use of a CO monitor in antenatal care should be presented as a choice, and not necessarily implemented as a universal screening tool as seen in the United Kingdom (UK). ‘Yeah, I suppose that would be good. I suppose consent as well, obviously. It can’t be something that’s forced on you…but, yep, definitely if it was offered, someone like myself would be like, oh cool.’ P11 DCO ‘…If you made it their choice like, that might be better. Or…just having it as Ok, we've got this here [CO monitor], if you want help or you know.’ P1 ICO 3.2.5 Decreased opportunity & capability : Collective barriers regardless of CO monitor Regardless of group, women described considerable barriers to smoking cessation/reduction related to the opportunity condition, and physical skills within the capability condition. Women were continually experiencing complex social relationships (social influences) and environmental stressors (Environment context & resources) that caused increased stress and anxiety. Women then continued to use smoking as a coping strategy regardless of the positive motivators established by CO monitor use. ‘…For something that's been so hard and so complicated, and now I've got something so important going on, but then, because of other stressors, I'm using it as a coping mechanism and it's like, ‘you're a fuckin' idiot’ for even picking up a cigarette…’ P2 DCO Furthermore, nearly half of the women interviewed also lived with other people who currently smoked and this had a substantial impact on their ability to change smoking behaviour. ‘ Participant : It makes it hard when everyone in my house smokes. Researcher : …How many other people around you do you have that smoke with you? Participant : Uh, usually two but sometimes three.’ P10 ICO While participants in the DCO group were at times able to reduce their passive smoking exposure by physically removing themselves from the social group, there was a sense of safety and acceptance, as well as normalisation in ‘having a cigarette’ with the social group. ‘Yeah, you know. I’m lucky in a – not lucky in a way but a lot of the people I associate – like am friends with and socialise with are smokers. So, when I go and see my family, like my sister and my dad, they’re smokers, when I go see a couple of friends, they’re smokers. So, I don’t feel isolated.’ P12 DCO ‘But to see someone else pick up a cigarette or have a cone [marijuana] it’s, you know, and then they're like, do you want one and it's just habit.’ P10 ICO With regard to physical skills (within the capability condition), women predominantly described using distraction in an attempt to disrupt the boredom and habit formation of smoking. They would use chores, craft activities, eating (lollies, gum or fruit) or smartphone applications (for distraction, not smoking-specific apps). The DCO group were able to at times successfully incorporate these methods with ‘thinking’ about their initial CO reading as a smoking deterrent. The ICO group however, having felt anxious and overwhelmed at using the monitor initially, actively avoided thinking of the monitor in an attempt to reduce their existing feelings of shame. ‘ Researcher : Yep, so, um, in terms of trying to cut down…? Participant : Eat a piece of fruit instead…Or go on – or I go on my phone and watch some video about some animal or kids, or something…Or just thinking about it [CO monitor reading], and thinking, yeah, nah, I don’t want one.’ P8 DCO ‘Yeah, I’ve been just folding and washing and folding and washing…clothes for…getting her ready…setting everything up, trying to keep…busy. I find myself, like, scrolling TikTok a lot…and you lose a few hours there…but, yeah, no [strategies]…nothing in particular, no.’ P13 ICO Physical skills continued to be decreased when considering the use of NRT. Very few participants used or sought NRT to manage nicotine withdrawal, despite this being discussed at the initial interview. Although, some participants in the DCO group had used NRT previously and had side effects with use (headaches, hives, nightmares, nausea and vomiting), they were therefore unwilling to consider using it again. No participants in the ICO group tried NRT, with cost specifically cited as a deterrent. Only 2 participants in the DCO group tried using NRT (inhalators in both cases) and were unenthusiastic about continuation. ‘…Like when I got here [hospital]…they gave me these [NRT inhalators]…It – the feeling in the back of the throat, it’s really hard to explain, it’s – well, obviously it’s nothing like a cigarette but the nicotine actually like bites into your throat and kind of has like a burning sensation. And if they were able to make it a bit more smooth, it would probably be helpful…’ P12 DCO While some women in the DCO group engaged social support (within the opportunity condition) for mental health management, only 1 participant, who was successful with cessation, accepted a Quitline referral, and engaged with the service. Women in both groups expressed a strong sense of self-reliance when considering smoking behaviour change, and explicitly felt that any discussion about smoking, cessation or otherwise with social support was counter-productive. ‘Oh nah, I think that's more than enough [CO monitor reading] to - like people can - like women can quit themself. Like they don’t need really a helplines and stuff…They would just need motivation with this machine I guess to see that they're dropping.’ P7 DCO 4. Discussion and Conclusion Given the limited literature to date on women’s perception of CO monitoring in pregnancy, this study provides considerable insight and understanding on the topic. Our study design using a CO monitor at two time points in pregnancy, coupled with in-depth qualitative interviews has allowed for meaningful exploration into the acceptance and value of CO monitor use in pregnancy. Using the monitor as an education intervention increased women’s capability condition by providing knowledge of the impact of smoking. However, depending on the mind-set of the participant at the time of first use, this could either motivate or inhibit smoking behaviour change. The differing responses of the two identified groups in this study is a unique finding not previously reported, and emphasises that CO monitor use in pregnancy should be carefully considered with particular reference to individual women’s circumstances. To date, the primary outcomes measured with reference to CO monitors in pregnancy have been the smoking cessation rate and women’s perceived acceptability. Some studies implementing universal screening with ‘opt-out’ referral pathways have shown an increase in identification of previously unreported smoking and therefore referral to smoking cessation services ( 31 , 32 ). However, this has not successfully shown a subsequent increase in the rate of smoking cessation ( 2 ). Conclusions have therefore been drawn that CO monitor use in pregnancy has limited efficacy. When considering the acceptability of CO monitor use in pregnancy to women, there has been narrow exploration with only four studies included in a recent systematic review ( 2 ). Significantly, two of these inclusions were women’s perceptions as interpreted by midwives and were conducted in areas of low smoking prevalence ( 20 , 33 ). Midwives felt there was general acceptance of routine CO monitoring by women ( 20 ) and described similar emotional responses as seen in the present study. These reactions were however not explored further, but midwives felt that in some cases the strong emotional responses could trigger cessation, although cessation rates were not reported ( 20 ). When pregnant women were engaged on the issue in other studies, they had positive perceptions of monitor use, although most found the monitor confronting and had limited contextual understanding of its use in smoking cessation ( 34 , 35 ). Midwives also observed this lack of understanding of monitor use in women ( 20 ). Women did however describe feeling motivated by monitor use to change smoking behaviour when used as part of a comprehensive intervention, although there was less acceptability to do so if smoking cessation was viewed as unachievable or contradicted their world view ( 35 ). These seemingly paradoxical attitudes can be better understood by the findings in our study. If we consider that there are two types of response to monitor use, neither of which necessarily result in smoking cessation, women as a cohort can appear both motivated to modify behaviour and overwhelmed to do so. The majority of women then, regardless of initial monitor use, can be further overwhelmed with pre-existing behavioural barriers that decrease their capability and opportunity conditions. Furthermore, if smoking cessation is considered an ongoing journey or process, as it was by women in the DCO group, then using a CO monitor over the course of pregnancy has value as a positive reinforcement tool. If we re-define ‘what success looks like’ with regard to smoking cessation, then CO monitor use in pregnancy could allow for women to make small, sustained behavioural changes that may eventually result in cessation. With copious literature describing the normalisation and embedded nature of smoking in women’s complex lives and pregnancies ( 18 , 36 , 37 ), the expectation on women to quit smoking in pregnancy can be considered by them as overwhelming and impractical. Therefore, changing our expectations of success to ‘incremental improvement’ could be beneficial for women who do want to change smoking behaviour in pregnancy. However, while this approach could assist women with longer-term smoking cessation goals and therefore offer considerable health benefits, it is unlikely to improve immediate birth outcomes for women and babies. For CO monitors to play a motivational role in smoking behaviour modification during pregnancy, they must be accessible for women to use. In the present study, women were not opposed to the implementation of CO monitors in routine antenatal care and felt this could be beneficial for ongoing change of smoking behaviour. However, they were clear that use of the monitor should be a choice, and that application should be facilitated by non-judgemental staff. Women in pregnancy perceive substantial judgment from health professionals resulting in feelings of guilt and/or shame ( 38 ). So much so, that they can assume judgment from all health providers that they interact with on the topic of smoking in pregnancy. Therefore, considering other ways women in pregnancy could regularly access CO monitors, irrespective of routine antenatal care, may improve its value as a positive reinforcer for behaviour change. Women suggested community locations, such as pharmacies, as places they could visit to use a CO monitor. Another potentially convenient option is the use of a personal CO monitor. A personal device such as this could be provided to pregnant women who smoke in the same manner that blood glucose monitors are routinely provided to women diagnosed with gestational diabetes (subsidised by the Australian government). Two publications from 2012 and 2018 ( 39 , 40 ) investigated the use of personal CO monitors for a general smoking population (males and females, non-pregnant). Participants in both studies were able to modify their smoking behaviour and use the monitors as positive reinforcers ( 39 , 40 ). In Beard and West (2012) ten participants were provided a personal CO monitor to use regularly through the day for 6 weeks. At follow up, all participants had a CO (ppm) lower than their initial baseline and reported a reduction in the number of cigarettes they were smoking daily ( 39 ), similar to the DCO group in the present study. Furthermore, over the 6 week trial, nine of the participants attempted quitting at different points with some remaining abstinent for days or weeks ( 39 ). Overall, participants felt having regular access to a CO monitor increased motivation to modify their smoking behaviour ( 39 ). Therefore, it is plausible that similar effects could be observed in a pregnancy sub-group (i.e. women who align with the DCO characteristics) when offered recurrent access to a CO monitor. The more recent study ( 40 ), examined not only introduction of a personal CO monitor for individuals who were smoking, but also a smartphone prototype application (CO Smartphone System - CSS). Participants were highly motivated to reduce their cigarette consumption while using the CSS. They were also interested in the ‘quantified self’, which the authors have defined as the assessment and documentation in detail of behaviour and outcomes, related to stages of quitting ( 40 ). Due to this finding, participants were particularly amenable to having long-term access to the CSS for smoking cessation ( 40 ). This is consistent with the participants in the DCO sub-group in the present study viewing smoking cessation as a process/journey and therefore considering a CO monitor that connects to a CSS for pregnancy could be transferable and highly valuable. Another consideration with the implementation of CO monitors in pregnancy for smoking behaviour change is providing the necessary social support to best facilitate that change. The findings presented here clearly indicate that social support for smoking cessation is distinctly lacking for pregnant South Australian (SA) women. In the United Kingdom, where universal CO monitoring has become standard practice in pregnancy, women are referred to and followed up repeatedly by a dedicated ‘stop smoking service’ (SSS) ( 32 ). There have been no empirical accounts documenting if the integration of CO monitoring with SSSs can act as a positive reinforcer and foster incremental smoking behaviour change; only the overall cessation rate. Participants in the CSS trial mentioned in the previous paragraph were keen to see the CO monitor and app integrated with the existing face-to-face programs in the UK for smoking cessation ( 40 ). This reinforces the value participants place on face-to-face social support for smoking behaviour change, within a healthcare system that has significantly invested in this area of public health. In SA the only social support offered to pregnant women is a referral to Quitline. Given women’s reluctance to engage with this service and their emphasis on self-reliance for changing smoking behaviour, efforts could be made to better support their attempts at smoking behaviour change and to normalise social support. Women’s previous experiences of feeling judgement/stigma, shame and/or guilt related to smoking in pregnancy ( 38 ) and these perceived attitudes from health providers ( 18 ), it is unsurprising that they would choose to withdraw from social support in a self-preserving fashion. However, in doing so they potentially constrain their smoking cessation efforts. Evidence has clearly demonstrated that empowering women with autonomy greatly improves their antenatal care ( 41 ) and multiple studies have found that allowing autonomy via the use of a CO monitor was essential for participants to experience the benefits of use ( 35 , 42 ). However, for best efficacy, the use of a CO monitor must be combined with high levels of support ( 35 ) that women perceive as useful. This has been reiterated by clinical experts on the inclusion of CO monitors in routine care ( 20 , 43 ). Peer-to-peer interactive support, in conjunction with CO monitor use, could provide an avenue of support for women who smoke that they would find acceptable. Our previous work has established that women view this idea positively ( 18 ). While there is limited evidence as to the effectiveness of peer support ( 44 , 45 ), there have been reports of women naturally seeking this level of support via antenatal classes ( 46 ). Considering the present averseness women have to smoking cessation support from health providers, and the unlikeliness that Australian smoking cessation services will extend beyond Quitline, enabling and facilitating interactive peer support where women feel understood and empathised with could be beneficial. Especially if the focus, and context of CO monitoring within that support is reinforcement (i.e. small behavioural changes over time that consistently decrease cigarette consumption) rather than cessation. While there are practical extensions of this trial that could be beneficial for the DCO sub-group of pregnant women (consistent access to a CO monitor, access to a pregnancy specific CSS and/or peer support), this may not be the case for all pregnant women, as represented by the ICO sub-group. Both groups expressed feeling guilt following using the CO monitor. Generally, an individual feels guilt when they have violated moral rules and imperatives, particularly causing suffering to others ( 47 ). It tends to occur within the context of communal relationships where an individual believes they have caused harm, loss or distress to a relationship partner ( 47 ). Smoking during pregnancy has the potential to harm the mother/child relationship. Therefore, women experiencing guilt could feel positively motivated to change behaviour in an attempt to make restitution for the transgression of smoking ( 47 ). In this circumstance, it is the action (smoking in pregnancy), not the self, that is bad ( 47 ). Guilty feelings can therefore resolve when a reparative action is offered (i.e. decreasing the number of cigarettes smoked) and the individual does not need to reassess their moral identity ( 48 ). For the DCO group, the feeling of guilt was assuaged when the second CO monitor reading validated that changing smoking behaviour had an impact. However, pregnant women in the ICO group not only experienced guilt, but shame and disgust also in response to using the CO monitor. Shame in comparison to guilt is defined not by the relationship with others, but by its contrast with others ( 47 ). It is characteristically provoked by an individual’s perception of violation of a moral norm that therefore painfully reveals the self to be flawed or defective ( 47 , 49 ). The consequences of shame can result in an individual reducing their social presence (withdrawing or hiding) and decreasing their motivation and power to act against the moral violation ( 47 , 48 ). Women in the ICO group experiencing shame and disgust when using the CO monitor, therefore may have felt condemned for their moral identity where the act of smoking in pregnancy was not distinct from the ‘bad-self’ they identified with. As previously mentioned, evoking shame is not conducive to behaviour change and is consistent with the minimal behaviour change reported in the ICO group. Evidence suggests that individuals can find it challenging to differentiate between guilt and shame, and therefore cannot easily classify their experiences as one or the other ( 50 ). Participants in this trial used the terms guilt and shame interchangeably. The authors therefore propose that the DCO group predominantly felt guilt (rather than shame) when using the CO monitor, which was useful for prompting smoking behaviour change. Whereas the ICO group predominantly felt shame (rather than guilt) when using the monitor and this resulted in the subsequent emotional spiral and cognitive overload causing an inability to change smoking behaviour. Shame can be a direct cause of poor health ( 51 ). It can heighten self-consciousness, negative affect and cognitive shock and thus be profoundly dysfunctional, disempowering and psychologically damaging ( 51 , 52 ). It is therefore crucial to assess an individual woman’s personal circumstances to determine if use of CO monitor in pregnancy has the potential to promote or dissuade positive change. Data presented here, as well as additional qualitative data collected in the trial, could inform a simple screening tool to ascertain if a CO monitor could be beneficial for individuals. Such a tool should also incorporate elements of the transtheoretical stages of change model to best assess an individual’s attitude to smoking behaviour change. Incorporating a CO monitor into antenatal care in this manner (on a screening case-by-case basis) may have greater impact on smoking behaviour change overall in pregnancy rather than universal screening. In conclusion, implementation of antenatal CO monitoring has the potential to assist some women with incremental smoking behaviour change through pregnancy, provided necessary support and access to a CO monitor is consistently available. Importantly however, for some women, use of a CO monitor will elicit a shame response preventing positive smoking behaviour change. Brief screening on a case-by-case basis to assess an individual’s circumstances and mind-set is likely to be key in determining if use would be supportive on women’s smoking cessation journey. Abbreviations CO Carbon Monoxide COM-B Capability, Opportunity, Motivation - Behaviour TDF Theoretical Domains Framework DCO Decreased CO ICO Increased CO ANZCTR Australian New Zealand Clinical Trials Registry AIHW Australian Health and Welfare Institute NRT Nicotine Replacement Therapy CALHN Central Adelaide Local Health Network HREC Human Research Ethics Commitee MGP Midwifery Group Practice SA South Australia RAT Rapid Antigen Test PPM Parts Per Million %COHb Maternal Blood Carboxyhaemoglobin %fCOHb Fetal Blood Carboxyhaemoglobin GP General Practitioner CI Clinical Investigator IRSD Index of Relative Socio-economic Disadvantage UK United Kingdom CSS CO Smartphone System SSS Stop Smoking Service Declarations Ethics approval statement This study that was approved by the Central Adelaide Local Health Network Human Research Ethics Committee on April 21 st 2021, approval number: 2021/HRE00038 Funding This project was funded by a Channel 7 Children’s Research Foundation grant, project reference 19/10674852 (awarded to LGS, GD, JL, EH). These funders were not involved in the study design, data collection or analysis, the interpretation of data, writing of this report or in the decision to submit this article for publication. Competing interests The authors have no relevant financial or non-financial interests to disclose. Authorship contribution statement Conceptualisation (CF, EH, AG, GD, JL, LGS); Data curation (CF, EH); Formal analysis (CF, EH); Funding acquisition (LGS, GD, JL, EH); Investigation (CF, EH, AG, LGS); Methodology (CF, EH, AG, LGS); Project administration (CF, EH, AG, LGS); Supervision (LGS); Writing – original draft (CF); Writing – review & editing (EH, AG, GD, JL, LGS). The author(s) read and approved the final manuscript. Data availability The data generated during and/or analysed during the current study are not publicly available in accordance with ethical approval for the study. Any bona fide researchers wanting to access data from this study would be contingent on further approvals from the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (HREC). Researchers should contact Prof Lisa Smithers. Consent for Publication Not applicable Acknowledgements We would like to thank the women who took the time to participate in this study, as well as the members of our Community Reference Group who assisted in shaping our project. We would also like to thank our community engagement officer Josephine Telfer and the many managers at community organisations for facilitating and assisting with recruitment. We would also like to thank hospital management for their assistance and encouragement with organising staff participation. References Gribble KD, Bewley S, Bartick MC, Mathisen R, Walker S, Gamble J, et al. Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language. 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Persuasive Moralising About the Risk of Smoking in Pregnancy Directly Impacts Maternal Self Worth and Esteem, Limiting Successful Cessation. Under review. 2025. Beard E, West R. Pilot study of the use of personal carbon monoxide monitoring to achieve radical smoking reduction. J Smok Cessat. 2012;7(1):12–7. Herbec A, Perski O, Shahab L, West R. Smokers' Views on Personal Carbon Monoxide Monitors, Associated Apps, and Their Use: An Interview and Think-Aloud Study. Int J Environ Res Public Health. 2018;15(2). Bowden C. Are we justified in introducing carbon monoxide testing to encourage smoking cessation in pregnant women? Health Care Anal. 2019;27(2):128–45. Grant A, Ashton K, Phillips R. Foucault, surveillance, and carbon monoxide testing within stop-smoking services. Qual Health Res. 2015;25(7):912–22. McClure JB. Are biomarkers a useful aid in smoking cessation? A review and analysis of the literature. Behav Med. 2010;27(1):37–47. Ford P, Clifford A, Gussy K, Gartner C. A systematic review of peer-support programs for smoking cessation in disadvantaged groups. Int J Environ Res Public Health. 2013;10(11):5507–22. Chamberlain C, O'Mara-Eves A, Porter J, Coleman T, Perlen SM, Thomas J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2:CD001055. Weiland S, Warmelink JC, Peters LL, Berger MY, Erwich J, Jansen D. The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study. Women Birth. 2021. Haidt J. The moral emotions. En RJ Davidson, KR Scherer y HH Goldsmith, editors, Handbook of affective sciences. Oxford: Oxford University Press. 2003. Manion JC. The moral relevance of shame. Am Philos Q. 2002;39(1):73–90. Tangney JP, Wagner P, Gramzow R. Proneness to shame, proneness to guilt, and psychopathology. J Abnorm Psychol. 1992;101(3):469–78. Bartky SL. Femininity and domination: Studies in the phenomenology of oppression. Routledge; 2015. Dolezal L, Lyons B. Health-related shame: an affective determinant of health? Med Humanit. 2017;43(4):257–63. Bradshaw J. Healing the shame that binds you: Recovery classics edition. Health Communications, Inc.; 2005. Footnotes The terms ‘maternal’ and ‘woman’ are used in this study as they are the preferred terminology in Australian health care settings. Alternative terms for ‘women’ and ‘mothers’ often involve references to anatomy or physiological processes. When referenced in this manner, it can feel reductionist and/or mechanistic. This can be perceived as ‘othering’ or dehumanizing populations who identify as women. With respect to women during pregnancy, birth and motherhood, there are increased efforts to reduce/exclude dehumanizing language in antenatal, intrapartum and post-natal care. Therefore, we chose to use the terms ‘woman’, ‘women’ and ‘maternal’ in this study ( 1 ). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6310946","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":455810239,"identity":"a1e1f7b7-e77d-427f-936e-4713e1b18797","order_by":0,"name":"Cherise Fletcher","email":"","orcid":"","institution":"University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Cherise","middleName":"","lastName":"Fletcher","suffix":""},{"id":455810240,"identity":"ac37ce8c-0b7f-4678-97a9-cd85f1607392","order_by":1,"name":"Elizabeth Hoon","email":"","orcid":"","institution":"University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Hoon","suffix":""},{"id":455810242,"identity":"0c29f85a-88ec-4c9c-b141-c7fe1908c403","order_by":2,"name":"Angela Gialamas","email":"","orcid":"","institution":"University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Angela","middleName":"","lastName":"Gialamas","suffix":""},{"id":455810243,"identity":"40f9d2f2-e208-4565-bf13-c54cfe8e67b1","order_by":3,"name":"Gustaaf Dekker","email":"","orcid":"","institution":"The Robinson Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Gustaaf","middleName":"","lastName":"Dekker","suffix":""},{"id":455810244,"identity":"d0ce1ab7-e85c-44bd-b1c0-dd3a49017f5b","order_by":4,"name":"John Lynch","email":"","orcid":"","institution":"University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"","lastName":"Lynch","suffix":""},{"id":455810245,"identity":"cf0d927c-db96-409a-b435-8c713af60d3c","order_by":5,"name":"Lisa Smithers","email":"data:image/png;base64,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","orcid":"","institution":"University of Adelaide","correspondingAuthor":true,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Smithers","suffix":""}],"badges":[],"createdAt":"2025-03-26 09:38:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6310946/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6310946/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82708386,"identity":"4debd754-8fa5-4d31-9bbb-5e8b00ea028f","added_by":"auto","created_at":"2025-05-14 11:01:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1305147,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6310946/v1/cc0a5651-9df0-4332-872f-3c619066324d.pdf"},{"id":82708020,"identity":"45766ba6-96e2-4105-a18b-974e736e0d45","added_by":"auto","created_at":"2025-05-14 10:53:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15937,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1InterviewScheduleBMCPublicHealth260325.docx","url":"https://assets-eu.researchsquare.com/files/rs-6310946/v1/c3526fa12d9c6788a4c2cb06.docx"},{"id":82708022,"identity":"544e270a-de46-4ae3-b2fa-98d5dde5e38f","added_by":"auto","created_at":"2025-05-14 10:53:59","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":2288329,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2SupportResourceBMCPublicHealth260325.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6310946/v1/4337b3e33394ed574e8fae15.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does use of a carbon monoxide (CO) monitor in pregnancy promote smoking behaviour change? A qualitative exploration using the COM-B framework","fulltext":[{"header":"1. Background","content":"\u003cp\u003eSmoking in pregnancy can have detrimental impacts on maternal\u003csup\u003e1\u003c/sup\u003e and fetal health, and remains a persistent problem in middle to high-income countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Women who smoke in pregnancy are at greater risk of experiencing pregnancy complications including miscarriage, preterm birth, stillbirth and placental abnormalities (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, their infants are at greater susceptibility of sudden infant death syndrome (SIDS) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and ongoing medical issues including respiratory dysfunction (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), impaired cognitive development (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and behavioural difficulties (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Complications related to smoking can have considerable impact on women and their families, as well as placing strain on an already over-extended maternity healthcare system (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Importantly, the adverse outcomes attributable to smoking in pregnancy can be reduced if women cease smoking prior to 20 weeks gestation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2022, the Australian Institute of Health and Welfare (AIHW) reported that 8.3% of pregnant women reported tobacco smoking at some point in their pregnancy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, smoking rates in pregnancy are higher among women living in socioeconomically disadvantaged circumstances (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Approximately 16% of women living in the most disadvantaged circumstances in Australia report smoking during pregnancy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is estimated that only 4% of women who smoke will cease smoking during pregnancy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and it is estimated that this is lower among women who live in disadvantaged circumstances (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The South Australian perinatal practice guidelines (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) currently recommend a brief intervention approach to smoking cessation in pregnancy using the 5A\u0026rsquo;s (Ask, Advise, Assess, Assist, Ask Again). This typically involves health providers completing a primary assessment at triage (first hospital visit) with women when they present at approximately 15\u0026ndash;20 weeks gestation. Health providers will enquire about smoking status, assess nicotine dependence and offer women who smoke a referral to the telephone counselling service Quitline. Other than Quitline, women are unlikely to be offered any other support or advice about cessation by health providers in the hospital service (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Previous work has distinctly indicated that pregnant women are reluctant to engage with Quitline, and generally find the service unhelpful and impractical (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Antenatal care provides an important and unique opportunity to address smoking, as women will have close contact with the healthcare system for an extended period. Given the reluctance of women to engage with Quitline, it is essential that alternative smoking cessation methods and motivators are explored and evaluated with pregnant women to determine whether they are understood as beneficial, acceptable and practical.\u003c/p\u003e \u003cp\u003eMonitoring carbon monoxide (CO) in expired air provides an opportunity for healthcare providers to discuss smoking and quitting support options with women who smoke during pregnancy (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). CO monitoring can be a motivating factor to quit and progress can be mapped with every quit attempt (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). One Australian pilot study reported that CO readings were the most encouraging factor for cessation, more so than the offer of Nicotine Replacement Therapy (NRT) and a Quitline referral (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Other studies have reported that CO monitoring is a potentially cost-effective means of encouraging smoking cessation, resulting in projected future savings for the healthcare system for smoking-related morbidity and mortality (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Our previous research has identified that women (unpublished) and midwives are interested in the potential for CO breath testing to facilitate conversations about smoking during pregnancy (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA recent systemic review explored CO testing in pregnancy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). A total of fifteen studies were included in the review spanning 1983\u0026ndash;2020. Universal CO testing with \u0026lsquo;opt-out\u0026rsquo; referral pathways, successfully increased referrals to cessation support, however, did not necessarily increase the identification of unreported smoking in pregnancy (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Mixed outcomes were observed for smoking cessation. Of the seven studies that specifically reported on smoking cessation, two found improved cessation rates while the remaining five did not (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Only four studies in the systematic review explored women\u0026rsquo;s perceptions of CO testing (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), with 2 reporting CO testing was acceptable. However, women felt they were not provided clear information regarding the output and this further created strain and distrust within the midwife/woman dyad (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGaudron and Davis (2024) concluded their systemic review stating that \u0026ldquo;\u003cem\u003eCO testing in pregnancy is also designed to motivate women to quit smoking, but there is very little evidence that it does so\u003c/em\u003e\u0026rdquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Given the distinct lack of evidence regarding women\u0026rsquo;s perceptions of CO implementation antenatally, we aim to explore the direct role it can play in smoking behaviour change when comprehensively considered within the Theoretical Domains and COM-B Frameworks.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Theoretical perspective\u003c/h2\u003e \u003cp\u003eA critical phenomenological approach was used to understand the lived experiences of women who engage with CO monitoring during antenatal care. This approach describes the meaning of experiences in terms of \u003cem\u003ewhat\u003c/em\u003e was experienced and \u003cem\u003ehow\u003c/em\u003e it was experienced (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), considered and informed by the Theoretical Domains Framework, COM-B model and behaviour change wheel (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). We take a constructionist epistemological position where meaning is understood to arise in and out of our engagement with the realities in our world and is advantageous in generating contextual understanding of a defined topic, for example, understanding how antenatal use of a CO monitor impacts smoking cessation (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe behaviour change wheel (BCW) is a model that incorporates multiple behaviour change theories. At the centre of the wheel is the COM-B model (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This is an acronym for the conditions capability (C), opportunity (O) and motivation (M), all which drive behaviour change (B) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). These conditions integrate the behavioural elements of the Theoretical Domains Framework (TDF) to describe the various facilitators and/or barriers that individuals may encounter as they attempt behaviour change, see Table\u0026nbsp;1. The COM-B model recognises that all 3 conditions flow in and out of each other to influence behaviour change, and that behavioural elements within each condition, can promote, dissuade or inhibit a desired behaviour change outcome. The BCW and COM-B can therefore be used to analyse a behaviour change intervention and determine if that intervention has a systematic approach to achieve change, and the proposed mechanisms of action (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). CO monitoring in pregnancy was therefore explored as an intervention function within this framework, and the individual conditional domains were considered as potential barriers and/or facilitators to smoking behaviour change.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDisplays the 3 COM-B conditions and how the behavioural elements of the\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eTheoretical Domains Framework are placed within each category.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCOM-B Condition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eSub-element\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTheoretical Domains Framework\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysical skill\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychological\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBehavioural regulation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMemory, attention \u0026amp; decision processes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnvironmental context \u0026amp; resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocial influences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReflective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSocial role \u0026amp; identity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBelief about capabilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOptimism\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBeliefs about consequences\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntentions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReinforcement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmotion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e This study was approved by the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (HREC), approval number 2021/HRE00038. All participants provided written informed consent prior to participating.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Sample and recruitment\u003c/h2\u003e \u003cp\u003eThis research study came from and was endorsed by a Community Reference Group, that was established to promote the overall program of work on smoking cessation in pregnancy for women living in northern Adelaide. Participants for this study included women (n\u0026thinsp;=\u0026thinsp;13) who smoked tobacco cigarettes during their pregnancy (any gestation) recruited between December 2021 and December 2022. Health professionals (obstetricians and midwives) in the antenatal clinic or Midwifery Group Practice (MGP) at a single metropolitan public hospital in South Australia (SA) conducted a brief eligibility screen of pregnant women who presented for antenatal care. This hospital is located in a region with the lowest quintile Index of Relative Socio-economic Advantage and Disadvantage of the Socio-Economic Indexes for Areas as indicated by the Australian Bureau of Statistics 2016 census data. If a pregnant woman was identified by antenatal clinic staff as currently smoking, they were asked to consent to a conversation with a researcher (CF) about the project. Eligibility was determined if women were over 18 years, could communicate in English without difficulty, and were willing and able to give informed consent for participation. The nature of the study, including what a CO monitor is, and the information that can be obtained from CO breath analysis was discussed. Women who agreed to participate, had contact details obtained and either organised to participate immediately in the antenatal clinic, or at a future convenient timepoint in the clinic or local community centre. If required, women were offered taxi vouchers to attend interviews at a local community centre.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection and analysis\u003c/h2\u003e \u003cp\u003e Once consent was obtained, participants completed a questionnaire collecting sociodemographic information. In accordance with ethics approval and maintaining the confidentiality of women, demographic data where \u003cem\u003en\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;5 will not be presented. Given the expiratory nature of using the CO monitor, participants were also asked to complete a Covid-19 rapid antigen test (RAT) (a condition stipulated by the public hospital divisional directors for participation). Participation was dependent on a negative RAT result. Women were then asked to use a calibrated CO monitor (PiCO Baby Smokerlyzer). CO breath analysis involved the participant taking a breath and holding it for 15 seconds, then blowing into a mouthpiece attached to the CO monitor to empty their lungs. CO readings were then displayed on the monitor for both the mother and the fetus. The CO level was explained to the participant with a poster (visual aid) provided by the manufacturer (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), which showed maternal and fetal CO content of blood. The monitor displays 3 numbers on completion of use: CO on the breath and in the lungs measured in ppm (0\u0026ndash;30+), maternal blood carboxyhaemoglobin (%COHb) and fetal blood carboxyhaemoglobin (%fCOHb) which measures the percentage of vital oxygen that has been replaced by CO in the bloodstream (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The numbers are colour coded and correlate approximately to the amount a person is smoking (green 0\u0026ndash;3 ppm non-smoker, amber 4\u0026ndash;6 ppm less than 10 cigarettes/day and red 7\u0026ndash;30\u0026thinsp;+\u0026thinsp;ppm greater than 15 cigarettes/day) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). CO readings were documented and the researcher (CF) conducted interviews with participants exploring questions detailed in Supplementary File 1. On completion of the scheduled interview questions, the researcher (CF) discussed and provided information relevant to support women\u0026rsquo;s mental health, as well as specific information related to smoking cessation, including NRT, Quitline, counselling and smart phone applications. This material can be found in Supplementary File 2 (Smoking cessation and support resource). Using the monitor, interview and discussing the smoking cessation support information was audio recorded with the participant\u0026rsquo;s consent. Interviews ranged in length from 15 to 50 minutes. Participants were also provided with a template letter to share with their general practitioner (GP) should they wish to access additional support.\u003c/p\u003e \u003cp\u003e Two to three days after CO monitor use and interview, participants received a welfare check via phone call or text from CF. This welfare check was to determine if they wanted assistance obtaining additional support. Approximately 4 weeks after the initial interview, women were contacted to establish a follow up interview (if smoking cessation was attempted, this is a reasonable length of time for behavioural changes to be established). This was either organised at the hospital at the participant\u0026rsquo;s next antenatal appointment or at a local community centre with the same researcher who had conducted the first interview (CF). Taxi vouchers were offered if meeting in a community space. Women completed a Covid-19 RAT, used the CO monitor for a second time and participated in another interview. Interview schedule for the second interview is detailed in Supplementary File 1. Again, using the monitor and the interview were audio recorded with the participant\u0026rsquo;s consent. Interviews ranged in length from 10 to 31 minutes. After completing the second interview, women were provided with a \u003cspan\u003e$\u003c/span\u003e50 gift card for their participation in the study. Women were free to withdraw from the study at any time, for any reason.\u003c/p\u003e \u003cp\u003eReflective discussions with the wider team (CF, EH, AG and LS) allowed debriefing on key learnings from interviews. The interviews (n\u0026thinsp;=\u0026thinsp;25) were transcribed by CI Fletcher or a transcriber who had signed a confidentiality agreement with the University. Transcripts were assessed against the original recording and reviewed. Participants were categorised into two groups, \u0026lsquo;Decreased CO\u0026rsquo; or \u0026lsquo;Increased CO\u0026rsquo;, determined by whether their CO (ppm) at second interview was less than, or greater than their CO (ppm) at first interview. Data was coded and thematically analysed as described by Clarke and Braun (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Data was coded deductively,. Data analysis was predominantly conducted by a single researcher (CF). Ongoing discussions with an experienced qualitative researcher (EH) allowed for a collaborative discussion of the applied coding framework. NVivo 12 qualitative software (QSR International) was used for coding and managing data.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Demographic characteristics\u003c/h2\u003e \u003cp\u003eA total of 13 participants were included in the study. Twelve participants completed both a first and second interview, with one participant lost to follow up and only completing a first interview. Characteristics of participants collected at the time of enrolment in the study are detailed in Table\u0026nbsp;2. All identified as women, were pregnant at inclusion of the trial with a mean gestation of 23 weeks (range 15\u0026ndash;32 weeks) and self-reported tobacco cigarette smoking in pregnancy. All women resided in areas with the lowest quintile Index of Relative Socio-economic Disadvantage (IRSD). This was reflected by over 65% of participants holding an Australian Healthcare card, where the Australian government sets eligibility at a weekly household income below \u003cspan\u003e$\u003c/span\u003eAUD 1,130.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSocio-demographic characteristics of study participants (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCharacteristic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge started smoking (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (\u003cspan additionalcitationids=\"CR14 CR15 CR16 CR17 CR18\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeeks gestation at enrolment in trial (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGravida\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not complete high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompleted high school or \u003c/p\u003e \u003cp\u003evocational training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCarer/home duties or unemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time or casual paid employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving with other people who smoke\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 CO readings for participants\u003c/h2\u003e \u003cp\u003eTable 3 displays the mean CO readings for participants by group at their first and second interviews. Seven women (including those that quit) demonstrated a decreased CO (ppm) reading at their second interview compared with their first (Decreased CO - DCO) and 6 women had CO (ppm) readings at second interview that were higher than their first (Increased CO - ICO). It was assumed that the participant lost to follow up at interview 2 had made minimal changes to their smoking behaviour and was thus included in the Increased CO group. This is consistent with the Russell standard that assumes non-attendance at subsequent visits indicates continued smoking (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). While researchers aimed to conduct a second interview at 4 weeks from the initial interview, the average time between interviews was 6 weeks. This was primarily due to scheduling issues. All readings at the first interview confirmed women were currently smoking. The majority of participants (~\u0026thinsp;77%, n\u0026thinsp;=\u0026thinsp;10) at first interview had a CO (ppm) greater than 9 (in red zone) indicating they were moderate to heavy smokers (~\u0026thinsp;20\u0026thinsp;+\u0026thinsp;cigarettes/day). Three women at the first interview received readings in the amber zone indicating light smoking (~\u0026thinsp;10 or less cigarettes/day). Two of these women were successful at smoking cessation at follow up as indicated by CO (ppm) readings in the green zone. At second interview, the majority of participants (75%, n\u0026thinsp;=\u0026thinsp;9), had a CO (ppm) greater than 7 (red zone) indicating that they remained moderate to heavy smokers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003e\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eMean CO (ppm) readings at each interview by group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean Interview 1\u003c/p\u003e \u003cp\u003eCO (ppm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Interview 2\u003c/p\u003e \u003cp\u003eCO (ppm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecreased CO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7 (58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased CO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026ndash;31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5 (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e*Participant lost to follow-up (LTF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Qualitative analysis\u003c/h2\u003e \u003cp\u003eQualitative analysis of the interview data identified differences across the COM-B conditions and subsequent TDF behavioural elements depending on the group. Women in the Decreased CO (DCO) group were more likely to have attempted cessation several times in the past and therefore appreciated that quitting was an ongoing journey and process. As they had attempted quitting in the past, they had some experience and/or knowledge of techniques to disrupt habit formation, vaping, NRT and social supports considered beneficial for supporting behaviour change.\u003c/p\u003e \u003cp\u003eBoth groups demonstrated an increased capability when the CO monitor was used as an education intervention to increase the knowledge/understanding of the impact of smoking (3.2.1). Following this knowledge increase, the DCO group were subsequently able to increase their motivational condition by forming intention and goals (behavioural elements) to change smoking behaviour (3.2.2). The Increased CO (ICO) group however, in response to the increased knowledge, exhibited decreased motivation with an emotional spiral and successive cognitive overload (3.2.3) that was not conducive to behaviour change.\u003c/p\u003e \u003cp\u003e For the DCO group, having formed specific intentions and goals that translated to small changes in behaviour, participants reported positive anticipation in knowing they would use the monitor again at a second interview. For this group there were further increases in the motivational condition with increases in reinforcement, optimism and belief about capabilities (3.2.4). The ICO group did not experience the same positive anticipation and reinforcement with repeat monitor use. However, they saw the value the CO monitor could provide if it were to be used in routine antenatal care (3.2.4). Finally, both groups revealed substantial barriers within the opportunity condition (social influences and environmental context/resources) and physical skills within the capability condition, irrespective of monitor use, that limited successful behavioural change (3.2.5).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 \u003cb\u003eIncreased capability\u003c/b\u003e: Knowledge increased as an education intervention\u003c/h2\u003e \u003cp\u003e When the CO monitor was used at the first interview with participants (both groups), it served as an education intervention function. That is, its use aimed to increase knowledge and understanding of the impact smoking can have on maternal and fetal health. Participants were initially unclear on how the CO reading was a proxy for smoking. However, once this was discussed with the researcher, women had a deeper understanding of smoking impact on monitor output.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;No one ever really mentioned the carbon monoxide, just that smoking\u0026rsquo;s bad.\u0026rsquo; P11 DCO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;It does sort of like make sense that umm, I suppose as to how many cigarettes I do smoke as yeah, as to how much carbon monoxide would be in my blood.\u0026rsquo; P1 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe zone colours (green, amber, red) and scale evident on the detailed manufacturer\u0026rsquo;s maternity chart provided clear information that was understood by participants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Like it puts a little bit of more of a shock factor into it, seeing the colours. I, I\u0026rsquo;d probably like the more information because each coloured section gives you an idea of like the green, you know\u0026hellip;light to non-smoker for orange, and then, yeah.\u0026rsquo; P12 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen acknowledged the importance of the information obtained from the CO monitor and felt that it was essential for any women who was smoking in pregnancy to understand.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;These are the things that you should, you know, pay attention too, of how much it's actually\u0026hellip;taking into your baby and how much you don't think is.\u0026rsquo; P3 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConsidering the COM-B conditions, it was evident CO monitor use increased women\u0026rsquo;s psychological capability by enhancing the knowledge behavioural element. Knowledge from the monitor was then able to have an influence on motivational conditions \u0026ndash; belief about consequence (reflective) \u0026ndash; and emotion (automatic). For the DCO group, output from the monitor allowed women to validate and accept the truth that smoking is damaging, as well as corroborating their dislike of smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;Because, like, I know smoking is bad for unborn babies and I want to change and quit for my child. Like even though if I wasn\u0026rsquo;t pregnant, I know it\u0026rsquo;s not good for me, and it\u0026rsquo;s not making my health any better.\u0026rsquo; P4 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;Oh my God, like I just hate smoking. Like I don't sit there and go, \u0026ldquo;Oh my God, I love cigarettes, everyone should smoke\u0026rdquo;. I think they're the most disgusting thing on the face of the planet. Like, they stink. Your hair's like\u0026hellip;stinks!\u0026rsquo; P2 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in the ICO group, however, held a less nuanced view of the damaging impact of smoking. They were therefore surprised by the CO reading and this subsequently affected their belief of consequence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Well, I thought it [unclear] not so bad but still in orange but no, in red. That\u0026rsquo;s terrible. Yeah, that\u0026rsquo;s not great.\u0026rsquo; P5 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;But it does \u0026ndash; it is a bit of an eye opener, that\u0026rsquo;s all, yeah, to see actually how much yeah, it does affect.\u0026rsquo; P6 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBoth groups expressed strong emotion when using the monitor. Most women found the monitor use confronting and described feeling disappointment, guilt and/or shame for smoking in pregnancy. The participants however felt that feeling guilty could be a motivator for change, and participants in the DCO group also felt gratitude at gaining greater knowledge about the impact of smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;I think you can guilt a lot of parents to quitting because I feel quite guilty seeing how high it is and I haven't had a smoke for ages\u0026hellip;\u0026rsquo; P3 ICO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Um. Yeah. It\u0026rsquo;s just putting a number on it, like it\u0026rsquo;s kind of a bit confronting when you look at the graph\u0026hellip;Ah, it\u0026rsquo;s a bit hard. It sucks.\u0026rsquo; P11 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Thank you for making me aware of it. That\u0026rsquo;s good.\u0026rsquo; P8 DCO\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor both groups, the guilt and/or shame felt from using the monitor was a reflection on how they perceived their social role and identity. Women wanted to identify as \u0026lsquo;good mothers\u0026rsquo; who care responsibly for their developing baby. In fact, most women who participated in this trial expressed that they had decreased smoking on learning of their pregnancy. This was in an attempt to develop a more responsible maternal identity. However, women\u0026rsquo;s perception of their social role and identity, and their emotional reactions to using the monitor, had different impacts on behavioural elements within the COM-B model for the DCO group vs the ICO group. This will be explored separately in sections 3.2.2 and 3.2.3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 \u003cb\u003eIncreased motivation\u003c/b\u003e: Women developing intent and goals for behaviour change (DCO group)\u003c/h2\u003e \u003cp\u003eAlthough women in the DCO group expressed feelings of guilt, and found the monitor use confronting, their mindset at the time of first monitor use meant that they formed specific intentions and goals with resolve to either quit smoking (n\u0026thinsp;=\u0026thinsp;2) or reduce the number of cigarettes they were smoking on a daily basis (n\u0026thinsp;=\u0026thinsp;5).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;But I have been focusing a lot, a lot more of what I can do to quit, at least looking at it in the future and not just going ohh, I'll think about it later, and it's\u0026hellip;been on my mind very frequently too, like everyday\u0026hellip;\u0026rsquo; P2 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;It\u0026rsquo;ll just make me think about it every time I have a cigarette now [CO monitor reading].\u0026rsquo; P8 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis was driven by their social role and identity to be \u0026lsquo;responsible mothers\u0026rsquo;, their feeling of gratitude for the additional knowledge of the impact smoking had on health, as well as expressed excitement and optimism that the CO monitor could be used as an indicator of behaviour change.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;So if someone\u0026rsquo;s trying to quit smoking and had a monitor like that that they could like monitor their levels and watch it [going] down might be a bit of a reward kind of thing, like, oh wow, like me not smoking 20 a day has made it go down to this and like the more I quit the lower it goes.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConsidering the transtheoretical model of behaviour change, women in the DCO group were more likely to be in the contemplation, preparation or action phases of the model and therefore use knowledge of the monitor to change behaviour.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eI guess [unclear] a different with other people, you know, with the certain ways that they want to go ahead with it. Like I guess with me, because I want to quit\u0026hellip;it's just a good motivation for me.\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eSo, do you feel if someone is in that frame of mind where they do want to make changes, that it could be really positive?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eMm-hm. Yep.\u0026rsquo; P7 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in this group were further aware that stress and anxiety due to poor mental health were significant barriers to changing smoking behaviour. Women described intent and determination with accessing mental health supports to better manage these feelings so that they had less impact on smoking behaviour.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I currently see the perinatal mental health here. I have constant contact with a mental health nurse here. I also see a counsellor through Relationships Australia. And I\u0026rsquo;m in the process of getting back with my psychologist.\u0026rsquo; P12 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;But it definitely helped with the anxiety side [NRT and GP assistance], which is what I really struggle with trying to quit.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in this group developed additional intentions to reduce the CO monitor reading at follow up by also actively removing themselves from others who were smoking. Thus, reducing the impact passive smoking would have on a future CO reading.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003e\u0026lsquo;Researcher\u003c/b\u003e: \u003cem\u003e\u0026hellip;Is that something that\u0026rsquo;s changed\u0026hellip;like not being around him as much when he\u0026rsquo;s having a cigarette?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYeah. I just tell him to go have a cigarette. I don\u0026rsquo;t \u0026ndash; or I\u0026rsquo;ll roll it and I won\u0026rsquo;t roll myself one\u0026hellip;\u0026rsquo; P8 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWith their intentions established, women were then able to generate constructive goals for changing smoking behaviour specifically related to the CO monitor. These included aiming to reduce the CO ppm at the next interview, not have it increase, or to reduce the colour zone at the next interview.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Definitely. I think it was \u0026ndash; it did have an impact seeing the number so high it kind of made me like, oh, I want to get it lower...\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Kind of go down to the green now.\u0026rsquo; P7 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe goals developed by the DCO group participants were then able to affect their decision processes and behavioural regulation capabilities. At interview 2, women retained the information from the CO monitor and indicated they \u0026lsquo;thought\u0026rsquo; about the ppm number or zone colour, and used this as a deterrent to having a cigarette in the moment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eDo you feel like having used the monitor when we did\u0026hellip;- did that influence...\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eOh, yeah\u0026hellip;A little bit, realising how much toxin's in me\u0026hellip;So yeah, it helped me push meself a bit more.\u0026rsquo; P4 DCO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;I just thought \u0026ndash; actually, I think it was just a thing I got in my head [CO monitor reading]\u0026hellip;\u0026rsquo; P8 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 \u003cb\u003eDecreased motivation\u003c/b\u003e: Emotional spiral \u0026amp; subsequent cognitive overload (ICO group)\u003c/h2\u003e \u003cp\u003eWomen in the ICO group had an overwhelming emotional response to using the CO monitor at the first interview and this impacted several behavioural elements within the COM-B conditions. They described feeling disappointed, shocked, disgusted and \u0026lsquo;feral\u0026rsquo; at the impact smoking was having on their baby\u0026rsquo;s health (not necessarily their own). Women therefore felt forced in this moment to acknowledge and accept the negative implications of smoking.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Made me feel like crap, to be honest, that she\u0026rsquo;s [fetus] getting that much.\u0026rsquo; P13 ICO\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Um, it\u0026rsquo;s pretty disgusting if it\u0026rsquo;s up that high. Like yeah, it\u0026rsquo;s not good\u0026hellip;I think more about the baby, yeah, but just, yeah, it\u0026rsquo;s not cool either way.\u0026rsquo; P6 ICO\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eConfronted with this reality and belief about consequence, women\u0026rsquo;s guilt and shame were amplified. They felt overwhelmed, stressed and anxious, all positive indicators of cognitive overload. Women predominantly reported using smoking as a coping mechanism to manage these feelings, hence the using of the monitor made women in the ICO group feel like they wanted a cigarette.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eNow that you\u0026rsquo;ve used the monitor, how do you feel about your smoking?\u003c/em\u003e\u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eLike I need a cigarette actually.\u0026rsquo; P5 ICO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cb\u003eResearcher\u003c/b\u003e:\u003cem\u003e\u0026hellip;It's now become a coping mechanism for you?\u003c/em\u003e\u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYeah like I just - I - to go to sleep at night I have to have a couple of ciggies otherwise I sit there and toss and turn all night\u0026hellip;so yeah, like, I pretty much rely on it as - it\u0026rsquo;s like medication to me.\u0026rsquo; P8 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in the ICO group nevertheless expressed a wish to identify as \u0026lsquo;good mothers\u0026rsquo; who reduce smoking in pregnancy (social role and identity). Thus, their motivational intention to \u0026lsquo;cut down\u0026rsquo; was founded in the abrupt emotional belief of consequence at using the monitor and how they felt a \u0026lsquo;good mother\u0026rsquo; \u003cem\u003eshould\u003c/em\u003e responsibly behave.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;I don't umm, I know for myself I should be feeling that, you know, that's still a fair bit for myself but I don't know why, but I don't feel like it, if it was just me, I wouldn't feel\u0026hellip;\u0026rsquo; P1 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;It\u0026rsquo;s just really opened my eyes to the fact of, that\u0026rsquo;s how much is actually going through, and she doesn\u0026rsquo;t need that. She doesn\u0026rsquo;t \u0026ndash; she can\u0026rsquo;t take that. Gee, that\u0026rsquo;s a lot, but \u0026ndash; yeah, no.\u0026rsquo; P13 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen women experienced the cognitive overload of using the monitor they felt forced to \u0026lsquo;second guess\u0026rsquo; their belief system about the impacts of smoking on fetal health. To manage this emotion they engaged lay epidemiology to self-soothe and refute current medical evidence (Memory, attention and decision processes), rather than believe the monitor output.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I think again, only because my baby, like the babies, have been healthy. I don't really think too much about the side effects of what it should do like long term or even that short term when it's growing\u0026hellip;\u0026rsquo; P3 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePrior to using the monitor at the first interview, the majority of women in the ICO group described having reduced the number of cigarettes they were smoking daily. Thus, they firmly believed that this would be reflected on the CO monitor. However, in most cases, the reading was higher than they expected (in the red zone), and this considerably decreased women\u0026rsquo;s belief in their capabilities and optimism that they could successfully change their smoking behaviour.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Umm, like I, I suppose I hadn't felt that bad because I'd I'd really cut back on my smoking. I still didn't feel OK that I was still smoking. But yeah\u0026hellip;\u0026rsquo; P1 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;I probably have to try and cut down a lot more than what I have. But, yeah, that\u0026rsquo;s harder said than uh done...\u0026rsquo; P10 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, several women in the ICO group were consuming alcohol or illicit drugs during pregnancy. They had been strongly advised by medical professionals to restrict these behaviours and this was the priority, rather than reducing or quitting cigarette smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eCos, I was umm, like before, I was smoking marijuana, which I'm not anymore\u0026hellip;I had a doctor say to me, he was very you know, old-fashioned\u0026hellip;And such said to me \u0026lsquo;You know, you shouldn't be doing that\u0026rsquo; and\u0026hellip;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eSo for the doctor was the priority marijuana stopping over tobacco smoking?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYes, yes.\u0026rsquo; P1 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTherefore, given that some women were already attempting to change other harmful behaviours, using the CO monitor was additionally overwhelming because they felt they needed smoking as a coping mechanism in the absence of other alcohol and/or drugs. This further decreased their belief in capability and optimism to successfully make changes to smoking behaviour. Already feeling guilt and shame, then experiencing the overwhelming stress, anxiety and confrontation of using the CO monitor, coupled with decreased belief in their capabilities and optimism, women continued to use smoking as a coping mechanism despite monitor use. Interestingly, this eventuation was predicted by the participants in The DCO group.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;You know, because I think that when you feel guilty about it, it actually makes you smoke more because you're feeling bad about yourself.\u0026rsquo; P2 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003e\u0026hellip;Your feeling is that giving women too much information\u0026hellip;could potentially just turn them off to\u0026hellip;\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eAnd then make them chain smoke afterwards.\u0026rsquo; P8 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite the overwhelming emotion felt by women in the ICO group and subsequent cognitive overload from CO monitor use, interestingly they deemed feeling guilty a necessary element to prompt or motivate behaviour change.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;No, well if it makes me feel bad, then obviously it would be helpful to kind of like, if people aren\u0026rsquo;t feeling bad about what they\u0026rsquo;re doing then they\u0026rsquo;re not going to change much, are they, so I guess feeling bad is not a bad thing in a way, because it makes you kind of want to do something more about it.\u0026rsquo; P6 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;It could in like some circumstances but in a way, like without that little bit of guilt, and that little bit of push, you don't get that urge to give up.\u0026rsquo; P10 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis then potentially places use of the CO monitor antenatally as a persuasion intervention function in addition to an education one. A persuasion intervention function uses communication to induce positive or negative feelings to promote behaviour change. Both groups report feeling emotion in response to using the CO monitor. For the DCO group, the combination of positive and negative emotion, as well as the improvement of other motivational behavioural elements is able to \u0026lsquo;persuade\u0026rsquo; behavioural change, albeit limited. However, for the ICO group, experiencing only a negative cascade of emotion, which in turn decreases other motivational behavioural elements, using the monitor is unsuccessful in \u0026lsquo;persuading\u0026rsquo; behaviour change.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4 \u003cb\u003eIncreased motivation\u003c/b\u003e: Positive reinforcement in repeated CO monitor use\u003c/h2\u003e \u003cp\u003eWomen in the DCO group were further motivated to regulate their smoking behaviour with the anticipation of repeated CO monitor use at the second interview. When their CO reading decreased, this provided positive reinforcement (reward) for changes to behaviour, even if small. Women described feeling pleased/happy, proud and excited that the CO reading decreased.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;But, yep, definitely if it was offered, someone like myself would be like, oh cool\u0026hellip;I get to use that at my appointment.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eOh. That\u0026rsquo;s hell good! Yeah. That\u0026rsquo;s really good.\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eDo you think that it\u0026rsquo;s nice to see that, um, you\u0026rsquo;ve made a change to your smoking, and it\u0026rsquo;s had an impact?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYeah. I can see it as well. When I cough up stuff in the morning, you can see it\u0026rsquo;s not as \u0026ndash; there as much.\u0026rsquo; P8 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I\u0026rsquo;m happy with it, that\u0026rsquo;s for sure\u0026hellip;Seeing it a bit lower is definitely good.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe emotion generated from positive reinforcement further improved women\u0026rsquo;s optimism and belief in their capabilities, and this was a motivator to continue to modify behaviour during pregnancy and reduce smoking.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I think it would be very cool to see, um, especially if you\u0026rsquo;re a heavy smoker I suppose, um, if you started using it when first started quitting and then seeing it go down, I think would really motivate you to keep quitting.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;But yeah, so, it\u0026rsquo;s not much but it obviously goes to show that it really does make a difference to cut down.\u0026rsquo; P12 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor the women in the ICO group however, the anticipation of repeated CO monitor use at interview 2 led to self-reported increases in their stress and anxiety. Women continued to use smoking as a coping mechanism when faced with these feelings. Women acknowledged that they were also fearful of using the monitor because their previous efforts to modify behaviour had not been reflected in the CO reading. Additionally, they felt they had not reflected on the monitor output and therefore had limited behavioural modification.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Haven't really considered too much [previous CO reading]\u0026hellip;Still, quite high, I remember that chart, fuck that's high.\u0026rsquo; P3 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003e\u0026hellip;That you\u0026rsquo;ve reflected on over the time?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYeah. A little bit. Like I thought it was going to affect me a lot more, to be honest\u0026hellip;And I\u0026rsquo;m a little bit gutted that it didn\u0026rsquo;t\u0026hellip;\u0026rsquo; P5 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile the women in the ICO group showed increased CO readings at the second interview, they acknowledged the value the CO monitor could have as a positive reinforcer for smoking reduction. They also suggested introduction of the CO monitor in early pregnancy for maximum influence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Yeah, like giving them the thought straight away [before 12 weeks gestation], like from the get go, as soon as they find out they're pregnant, especially in the early stages because that's when everyone worries the most.\u0026rsquo; P10 ICO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003e\u0026hellip;You would see the number come down, do you think that that's a positive?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eThat is. Yeah, yep. No, definitely, if they see a change in it umm they might, you know, that will help them think, \u0026lsquo;well, I am doing something that's working\u0026rsquo;. P1 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs both groups could see value in using the CO monitor as a positive reinforcer, they were receptive to the idea of increased use in routine antenatal care, as well as in local pharmacies for autonomous independent use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;I think that it's a good thing [using CO monitor in pregnancy], but I think it's been helpful that I don't feel judged. I think it would really depend on the people who are doing it.\u0026rsquo; P2 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eDo you think using something like this more regularly in antenatal care could be a good thing?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eYeah\u0026hellip;It'll help girls realise...how much of it is in their body.\u0026rsquo; P4 DCO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eDo you think that would help with women\u0026rsquo;s motivation if they\u0026hellip;were able to test themselves more often?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eOh yeah. I reckon. Yeah. That\u0026rsquo;s what I mean. If you see it going down, you\u0026rsquo;re gonna be like, fuck yeah. Oh sorry.\u0026rsquo; P5 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWomen in both groups did however feel that use of a CO monitor in antenatal care should be presented as a choice, and not necessarily implemented as a universal screening tool as seen in the United Kingdom (UK).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Yeah, I suppose that would be good. I suppose consent as well, obviously. It can\u0026rsquo;t be something that\u0026rsquo;s forced on you\u0026hellip;but, yep, definitely if it was offered, someone like myself would be like, oh cool.\u0026rsquo; P11 DCO\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;If you made it their choice like, that might be better. Or\u0026hellip;just having it as Ok, we've got this here [CO monitor], if you want help or you know.\u0026rsquo; P1 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.5 \u003cb\u003eDecreased opportunity \u0026amp; capability\u003c/b\u003e: Collective barriers regardless of CO monitor\u003c/h2\u003e \u003cp\u003eRegardless of group, women described considerable barriers to smoking cessation/reduction related to the opportunity condition, and physical skills within the capability condition. Women were continually experiencing complex social relationships (social influences) and environmental stressors (Environment context \u0026amp; resources) that caused increased stress and anxiety. Women then continued to use smoking as a coping strategy regardless of the positive motivators established by CO monitor use.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;For something that's been so hard and so complicated, and now I've got something so important going on, but then, because of other stressors, I'm using it as a coping mechanism and it's like, \u0026lsquo;you're a fuckin' idiot\u0026rsquo; for even picking up a cigarette\u0026hellip;\u0026rsquo; P2 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, nearly half of the women interviewed also lived with other people who currently smoked and this had a substantial impact on their ability to change smoking behaviour.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eIt makes it hard when everyone in my house smokes.\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e:\u003cem\u003e\u0026hellip;How many other people around you do you have that smoke with you?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eUh, usually two but sometimes three.\u0026rsquo; P10 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e While participants in the DCO group were at times able to reduce their passive smoking exposure by physically removing themselves from the social group, there was a sense of safety and acceptance, as well as normalisation in \u0026lsquo;having a cigarette\u0026rsquo; with the social group.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Yeah, you know. I\u0026rsquo;m lucky in a \u0026ndash; not lucky in a way but a lot of the people I associate \u0026ndash; like am friends with and socialise with are smokers. So, when I go and see my family, like my sister and my dad, they\u0026rsquo;re smokers, when I go see a couple of friends, they\u0026rsquo;re smokers. So, I don\u0026rsquo;t feel isolated.\u0026rsquo; P12 DCO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;But to see someone else pick up a cigarette or have a cone [marijuana] it\u0026rsquo;s, you know, and then they're like, do you want one and it's just habit.\u0026rsquo; P10 ICO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWith regard to physical skills (within the capability condition), women predominantly described using distraction in an attempt to disrupt the boredom and habit formation of smoking. They would use chores, craft activities, eating (lollies, gum or fruit) or smartphone applications (for distraction, not smoking-specific apps). The DCO group were able to at times successfully incorporate these methods with \u0026lsquo;thinking\u0026rsquo; about their initial CO reading as a smoking deterrent. The ICO group however, having felt anxious and overwhelmed at using the monitor initially, actively avoided thinking of the monitor in an attempt to reduce their existing feelings of shame.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;\u003c/em\u003e \u003cb\u003eResearcher\u003c/b\u003e: \u003cem\u003eYep, so, um, in terms of trying to cut down\u0026hellip;?\u003c/em\u003e \u003cb\u003eParticipant\u003c/b\u003e: \u003cem\u003eEat a piece of fruit instead\u0026hellip;Or go on \u0026ndash; or I go on my phone and watch some video about some animal or kids, or something\u0026hellip;Or just thinking about it [CO monitor reading], and thinking, yeah, nah, I don\u0026rsquo;t want one.\u0026rsquo; P8 DCO\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Yeah, I\u0026rsquo;ve been just folding and washing and folding and washing\u0026hellip;clothes for\u0026hellip;getting her ready\u0026hellip;setting everything up, trying to keep\u0026hellip;busy. I find myself, like, scrolling TikTok a lot\u0026hellip;and you lose a few hours there\u0026hellip;but, yeah, no [strategies]\u0026hellip;nothing in particular, no.\u0026rsquo; P13 ICO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePhysical skills continued to be decreased when considering the use of NRT. Very few participants used or sought NRT to manage nicotine withdrawal, despite this being discussed at the initial interview. Although, some participants in the DCO group had used NRT previously and had side effects with use (headaches, hives, nightmares, nausea and vomiting), they were therefore unwilling to consider using it again. No participants in the ICO group tried NRT, with cost specifically cited as a deterrent. Only 2 participants in the DCO group tried using NRT (inhalators in both cases) and were unenthusiastic about continuation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;\u0026hellip;Like when I got here [hospital]\u0026hellip;they gave me these [NRT inhalators]\u0026hellip;It \u0026ndash; the feeling in the back of the throat, it\u0026rsquo;s really hard to explain, it\u0026rsquo;s \u0026ndash; well, obviously it\u0026rsquo;s nothing like a cigarette but the nicotine actually like bites into your throat and kind of has like a burning sensation. And if they were able to make it a bit more smooth, it would probably be helpful\u0026hellip;\u0026rsquo; P12 DCO\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile some women in the DCO group engaged social support (within the opportunity condition) for mental health management, only 1 participant, who was successful with cessation, accepted a Quitline referral, and engaged with the service. Women in both groups expressed a strong sense of self-reliance when considering smoking behaviour change, and explicitly felt that \u003cem\u003eany\u003c/em\u003e discussion about smoking, cessation or otherwise with social support was counter-productive.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026lsquo;Oh nah, I think that's more than enough [CO monitor reading] to - like people can - like women can quit themself. Like they don\u0026rsquo;t need really a helplines and stuff\u0026hellip;They would just need motivation with this machine I guess to see that they're dropping.\u0026rsquo; P7 DCO\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion and Conclusion","content":"\u003cp\u003eGiven the limited literature to date on women\u0026rsquo;s perception of CO monitoring in pregnancy, this study provides considerable insight and understanding on the topic. Our study design using a CO monitor at two time points in pregnancy, coupled with in-depth qualitative interviews has allowed for meaningful exploration into the acceptance and value of CO monitor use in pregnancy. Using the monitor as an education intervention increased women\u0026rsquo;s capability condition by providing knowledge of the impact of smoking. However, depending on the mind-set of the participant at the time of first use, this could either motivate or inhibit smoking behaviour change. The differing responses of the two identified groups in this study is a unique finding not previously reported, and emphasises that CO monitor use in pregnancy should be carefully considered with particular reference to individual women\u0026rsquo;s circumstances.\u003c/p\u003e \u003cp\u003eTo date, the primary outcomes measured with reference to CO monitors in pregnancy have been the smoking cessation rate and women\u0026rsquo;s perceived acceptability. Some studies implementing universal screening with \u0026lsquo;opt-out\u0026rsquo; referral pathways have shown an increase in identification of previously unreported smoking and therefore referral to smoking cessation services (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). However, this has not successfully shown a subsequent increase in the rate of smoking cessation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Conclusions have therefore been drawn that CO monitor use in pregnancy has limited efficacy. When considering the acceptability of CO monitor use in pregnancy to women, there has been narrow exploration with only four studies included in a recent systematic review (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Significantly, two of these inclusions were women\u0026rsquo;s perceptions as interpreted by midwives and were conducted in areas of low smoking prevalence (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Midwives felt there was general acceptance of routine CO monitoring by women (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and described similar emotional responses as seen in the present study. These reactions were however not explored further, but midwives felt that in some cases the strong emotional responses could trigger cessation, although cessation rates were not reported (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). When pregnant women were engaged on the issue in other studies, they had positive perceptions of monitor use, although most found the monitor confronting and had limited contextual understanding of its use in smoking cessation (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Midwives also observed this lack of understanding of monitor use in women (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Women did however describe feeling motivated by monitor use to change smoking behaviour when used as part of a comprehensive intervention, although there was less acceptability to do so if smoking cessation was viewed as unachievable or contradicted their world view (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These seemingly paradoxical attitudes can be better understood by the findings in our study. If we consider that there are two types of response to monitor use, neither of which necessarily result in smoking cessation, women as a cohort can appear both motivated to modify behaviour and overwhelmed to do so. The majority of women then, regardless of initial monitor use, can be further overwhelmed with pre-existing behavioural barriers that decrease their capability and opportunity conditions. Furthermore, if smoking cessation is considered an ongoing journey or process, as it was by women in the DCO group, then using a CO monitor over the course of pregnancy has value as a positive reinforcement tool. If we re-define \u0026lsquo;what success looks like\u0026rsquo; with regard to smoking cessation, then CO monitor use in pregnancy could allow for women to make small, sustained behavioural changes that may eventually result in cessation. With copious literature describing the normalisation and embedded nature of smoking in women\u0026rsquo;s complex lives and pregnancies (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), the expectation on women to quit smoking in pregnancy can be considered by them as overwhelming and impractical. Therefore, changing our expectations of success to \u0026lsquo;incremental improvement\u0026rsquo; could be beneficial for women who \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003edo\u003c/span\u003e want to change smoking behaviour in pregnancy. However, while this approach could assist women with longer-term smoking cessation goals and therefore offer considerable health benefits, it is unlikely to improve immediate birth outcomes for women and babies.\u003c/p\u003e \u003cp\u003eFor CO monitors to play a motivational role in smoking behaviour modification during pregnancy, they must be accessible for women to use. In the present study, women were not opposed to the implementation of CO monitors in routine antenatal care and felt this could be beneficial for ongoing change of smoking behaviour. However, they were clear that use of the monitor should be a choice, and that application should be facilitated by non-judgemental staff. Women in pregnancy perceive substantial judgment from health professionals resulting in feelings of guilt and/or shame (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). So much so, that they can assume judgment from all health providers that they interact with on the topic of smoking in pregnancy. Therefore, considering other ways women in pregnancy could regularly access CO monitors, irrespective of routine antenatal care, may improve its value as a positive reinforcer for behaviour change. Women suggested community locations, such as pharmacies, as places they could visit to use a CO monitor. Another potentially convenient option is the use of a personal CO monitor. A personal device such as this could be provided to pregnant women who smoke in the same manner that blood glucose monitors are routinely provided to women diagnosed with gestational diabetes (subsidised by the Australian government).\u003c/p\u003e \u003cp\u003eTwo publications from 2012 and 2018 (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) investigated the use of personal CO monitors for a general smoking population (males and females, non-pregnant). Participants in both studies were able to modify their smoking behaviour and use the monitors as positive reinforcers (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In Beard and West (2012) ten participants were provided a personal CO monitor to use regularly through the day for 6 weeks. At follow up, all participants had a CO (ppm) lower than their initial baseline and reported a reduction in the number of cigarettes they were smoking daily (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), similar to the DCO group in the present study. Furthermore, over the 6 week trial, nine of the participants attempted quitting at different points with some remaining abstinent for days or weeks (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Overall, participants felt having regular access to a CO monitor increased motivation to modify their smoking behaviour (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Therefore, it is plausible that similar effects could be observed in a pregnancy sub-group (i.e. women who align with the DCO characteristics) when offered recurrent access to a CO monitor. The more recent study (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), examined not only introduction of a personal CO monitor for individuals who were smoking, but also a smartphone prototype application (CO Smartphone System - CSS). Participants were highly motivated to reduce their cigarette consumption while using the CSS. They were also interested in the \u0026lsquo;quantified self\u0026rsquo;, which the authors have defined as the assessment and documentation in detail of behaviour and outcomes, related to stages of quitting (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Due to this finding, participants were particularly amenable to having long-term access to the CSS for smoking cessation (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This is consistent with the participants in the DCO sub-group in the present study viewing smoking cessation as a process/journey and therefore considering a CO monitor that connects to a CSS for pregnancy could be transferable and highly valuable.\u003c/p\u003e \u003cp\u003eAnother consideration with the implementation of CO monitors in pregnancy for smoking behaviour change is providing the necessary social support to best facilitate that change. The findings presented here clearly indicate that social support for smoking cessation is distinctly lacking for pregnant South Australian (SA) women. In the United Kingdom, where universal CO monitoring has become standard practice in pregnancy, women are referred to and followed up repeatedly by a dedicated \u0026lsquo;stop smoking service\u0026rsquo; (SSS) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). There have been no empirical accounts documenting if the integration of CO monitoring with SSSs can act as a positive reinforcer and foster incremental smoking behaviour change; only the overall cessation rate. Participants in the CSS trial mentioned in the previous paragraph were keen to see the CO monitor and app integrated with the existing face-to-face programs in the UK for smoking cessation (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This reinforces the value participants place on face-to-face social support for smoking behaviour change, within a healthcare system that has significantly invested in this area of public health. In SA the only social support offered to pregnant women is a referral to Quitline. Given women\u0026rsquo;s reluctance to engage with this service and their emphasis on self-reliance for changing smoking behaviour, efforts could be made to better support their attempts at smoking behaviour change and to normalise social support. Women\u0026rsquo;s previous experiences of feeling judgement/stigma, shame and/or guilt related to smoking in pregnancy (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) and these perceived attitudes from health providers (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), it is unsurprising that they would choose to withdraw from social support in a self-preserving fashion. However, in doing so they potentially constrain their smoking cessation efforts. Evidence has clearly demonstrated that empowering women with autonomy greatly improves their antenatal care (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) and multiple studies have found that allowing autonomy via the use of a CO monitor was essential for participants to experience the benefits of use (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). However, for best efficacy, the use of a CO monitor must be combined with high levels of support (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) that women perceive as useful. This has been reiterated by clinical experts on the inclusion of CO monitors in routine care (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Peer-to-peer interactive support, in conjunction with CO monitor use, could provide an avenue of support for women who smoke that they would find acceptable. Our previous work has established that women view this idea positively (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). While there is limited evidence as to the effectiveness of peer support (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), there have been reports of women naturally seeking this level of support via antenatal classes (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Considering the present averseness women have to smoking cessation support from health providers, and the unlikeliness that Australian smoking cessation services will extend beyond Quitline, enabling and facilitating interactive peer support where women feel understood and empathised with could be beneficial. Especially if the focus, and context of CO monitoring within that support is reinforcement (i.e. small behavioural changes over time that consistently decrease cigarette consumption) rather than cessation.\u003c/p\u003e \u003cp\u003eWhile there are practical extensions of this trial that could be beneficial for the DCO sub-group of pregnant women (consistent access to a CO monitor, access to a pregnancy specific CSS and/or peer support), this may not be the case for all pregnant women, as represented by the ICO sub-group. Both groups expressed feeling guilt following using the CO monitor. Generally, an individual feels guilt when they have violated moral rules and imperatives, particularly causing suffering to others (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). It tends to occur within the context of communal relationships where an individual believes they have caused harm, loss or distress to a relationship partner (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Smoking during pregnancy has the potential to harm the mother/child relationship. Therefore, women experiencing guilt could feel positively motivated to change behaviour in an attempt to make restitution for the transgression of smoking (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In this circumstance, it is the action (smoking in pregnancy), not the self, that is bad (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Guilty feelings can therefore resolve when a reparative action is offered (i.e. decreasing the number of cigarettes smoked) and the individual does not need to reassess their moral identity (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). For the DCO group, the feeling of guilt was assuaged when the second CO monitor reading validated that changing smoking behaviour had an impact. However, pregnant women in the ICO group not only experienced guilt, but shame and disgust also in response to using the CO monitor. Shame in comparison to guilt is defined not by the relationship with others, but by its contrast with others (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). It is characteristically provoked by an individual\u0026rsquo;s perception of violation of a moral norm that therefore painfully reveals the self to be flawed or defective (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). The consequences of shame can result in an individual reducing their social presence (withdrawing or hiding) and decreasing their motivation and power to act against the moral violation (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Women in the ICO group experiencing shame and disgust when using the CO monitor, therefore may have felt condemned for their moral identity where the act of smoking in pregnancy was not distinct from the \u0026lsquo;bad-self\u0026rsquo; they identified with. As previously mentioned, evoking shame is not conducive to behaviour change and is consistent with the minimal behaviour change reported in the ICO group. Evidence suggests that individuals can find it challenging to differentiate between guilt and shame, and therefore cannot easily classify their experiences as one or the other (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Participants in this trial used the terms guilt and shame interchangeably. The authors therefore propose that the DCO group predominantly felt guilt (rather than shame) when using the CO monitor, which was useful for prompting smoking behaviour change. Whereas the ICO group predominantly felt shame (rather than guilt) when using the monitor and this resulted in the subsequent emotional spiral and cognitive overload causing an inability to change smoking behaviour. Shame can be a direct cause of poor health (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). It can heighten self-consciousness, negative affect and cognitive shock and thus be profoundly dysfunctional, disempowering and psychologically damaging (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). It is therefore crucial to assess an individual woman\u0026rsquo;s personal circumstances to determine if use of CO monitor in pregnancy has the potential to promote or dissuade positive change. Data presented here, as well as additional qualitative data collected in the trial, could inform a simple screening tool to ascertain if a CO monitor could be beneficial for individuals. Such a tool should also incorporate elements of the transtheoretical stages of change model to best assess an individual\u0026rsquo;s attitude to smoking behaviour change. Incorporating a CO monitor into antenatal care in this manner (on a screening case-by-case basis) may have greater impact on smoking behaviour change overall in pregnancy rather than universal screening.\u003c/p\u003e \u003cp\u003eIn conclusion, implementation of antenatal CO monitoring has the potential to assist some women with incremental smoking behaviour change through pregnancy, provided necessary support and access to a CO monitor is consistently available. Importantly however, for some women, use of a CO monitor will elicit a shame response preventing positive smoking behaviour change. Brief screening on a case-by-case basis to assess an individual\u0026rsquo;s circumstances and mind-set is likely to be key in determining if use would be supportive on women\u0026rsquo;s smoking cessation journey.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCarbon Monoxide\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOM-B\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCapability, Opportunity, Motivation - Behaviour\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eTDF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTheoretical Domains Framework\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDCO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDecreased CO\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eICO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIncreased CO\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eANZCTR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian New Zealand Clinical Trials Registry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAIHW\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian Health and Welfare Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNRT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNicotine Replacement Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCALHN\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Adelaide Local Health Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHREC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Research Ethics Commitee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMGP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMidwifery Group Practice\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouth Australia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRAT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRapid Antigen Test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePPM\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eParts Per Million\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003e%COHb\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMaternal Blood Carboxyhaemoglobin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003e%fCOHb\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFetal Blood Carboxyhaemoglobin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eGP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical Investigator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIRSD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIndex of Relative Socio-economic Disadvantage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCO Smartphone System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStop Smoking Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study that was approved by the Central Adelaide Local Health Network Human Research Ethics Committee on April 21\u003csup\u003est\u003c/sup\u003e 2021, approval number: 2021/HRE00038\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was funded by a Channel 7 Children\u0026rsquo;s Research Foundation grant, project reference 19/10674852 (awarded to LGS, GD, JL, EH). These funders were not involved in the study design, data collection or analysis, the interpretation of data, writing of this report or in the decision to submit this article for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthorship contribution statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualisation (CF, EH, AG, GD, JL, LGS); Data curation (CF, EH); Formal analysis (CF, EH); Funding acquisition (LGS, GD, JL, EH); Investigation (CF, EH, AG, LGS); Methodology (CF, EH, AG, LGS); Project administration (CF, EH, AG, LGS); Supervision (LGS); Writing \u0026ndash; original draft (CF); Writing \u0026ndash; review \u0026amp; editing (EH, AG, GD, JL, LGS). The author(s) read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated during and/or analysed during the current study are not publicly available in accordance with ethical approval for the study. Any bona fide researchers wanting to access data from this study would be contingent on further approvals from the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (HREC). Researchers should contact Prof Lisa Smithers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the women who took the time to participate in this study, as well as the members of our Community Reference Group who assisted in shaping our project. We would also like to thank our community engagement officer Josephine Telfer and the many managers at community organisations for facilitating and assisting with recruitment. We would also like to thank hospital management for their assistance and encouragement with organising staff participation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGribble KD, Bewley S, Bartick MC, Mathisen R, Walker S, Gamble J, et al. Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language. Front Glob Womens Health. 2022;3:818856.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaudron E, Davis DL. Is carbon monoxide testing in pregnancy an acceptable and effective smoking cessation initiative? An integrative systematic review of evidence. Women Birth. 2024;37(1):118\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanderali G, Martelli A, Landi M, Moretti F, Betti F, Radaelli G, et al. Short and long term health effects of parental tobacco smoking during pregnancy and lactation: a descriptive review. J Transl Med. 2015;13:327.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDietz PM, England LJ, Shapiro-Mendoza CK, Tong VT, Farr SL, Callaghan WM. Infant morbidity and mortality attributable to prenatal smoking in the U.S. Am J Prev Med. 2010;39(1):45\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaakkola JJ, Gissler M. Maternal smoking in pregnancy, fetal development, and childhood asthma. Am J Public Health. 2004;94(1):136\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchneider S, Huy C, Schutz J, Diehl K. Smoking cessation during pregnancy: a systematic literature review. 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Pregnant Women's Experiences and Views on an Opt-Out Referral Pathway to Specialist Smoking Cessation Support: A Qualitative Evaluation. Nicotine Tob Res. 2016;18(5):900\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones SE, Hamilton S, Bell R, Araujo-Soares V, White M. Acceptability of a cessation intervention for pregnant smokers: a qualitative study guided by Normalization Process Theory. BMC Public Health. 2020;20(1):1512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlemming K, Graham H, Heirs M, Fox D, Sowden A. Smoking in pregnancy: a systematic review of qualitative research of women who commence pregnancy as smokers. J Adv Nurs. 2013;69(5):1023\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlemming K, McCaughan D, Angus K, Graham H. Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth. 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Are we justified in introducing carbon monoxide testing to encourage smoking cessation in pregnant women? Health Care Anal. 2019;27(2):128\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrant A, Ashton K, Phillips R. Foucault, surveillance, and carbon monoxide testing within stop-smoking services. Qual Health Res. 2015;25(7):912\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClure JB. Are biomarkers a useful aid in smoking cessation? A review and analysis of the literature. Behav Med. 2010;27(1):37\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFord P, Clifford A, Gussy K, Gartner C. A systematic review of peer-support programs for smoking cessation in disadvantaged groups. Int J Environ Res Public Health. 2013;10(11):5507\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChamberlain C, O'Mara-Eves A, Porter J, Coleman T, Perlen SM, Thomas J, et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev. 2017;2:CD001055.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiland S, Warmelink JC, Peters LL, Berger MY, Erwich J, Jansen D. The needs of women and their partners regarding professional smoking cessation support during pregnancy: A qualitative study. Women Birth. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaidt J. The moral emotions. En RJ Davidson, KR Scherer y HH Goldsmith, editors, Handbook of affective sciences. Oxford: Oxford University Press. 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManion JC. The moral relevance of shame. Am Philos Q. 2002;39(1):73\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTangney JP, Wagner P, Gramzow R. Proneness to shame, proneness to guilt, and psychopathology. J Abnorm Psychol. 1992;101(3):469\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBartky SL. Femininity and domination: Studies in the phenomenology of oppression. Routledge; 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDolezal L, Lyons B. Health-related shame: an affective determinant of health? Med Humanit. 2017;43(4):257\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradshaw J. Healing the shame that binds you: Recovery classics edition. Health Communications, Inc.; 2005.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThe terms \u0026lsquo;maternal\u0026rsquo; and \u0026lsquo;woman\u0026rsquo; are used in this study as they are the preferred terminology in Australian health care settings. Alternative terms for \u0026lsquo;women\u0026rsquo; and \u0026lsquo;mothers\u0026rsquo; often involve references to anatomy or physiological processes. When referenced in this manner, it can feel reductionist and/or mechanistic. This can be perceived as \u0026lsquo;othering\u0026rsquo; or dehumanizing populations who identify as women. With respect to women during pregnancy, birth and motherhood, there are increased efforts to reduce/exclude dehumanizing language in antenatal, intrapartum and post-natal care. Therefore, we chose to use the terms \u0026lsquo;woman\u0026rsquo;, \u0026lsquo;women\u0026rsquo; and \u0026lsquo;maternal\u0026rsquo; in this study (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tobacco Smoking, Pregnancy, Carbon Monoxide Monitoring, COM-B, Theoretical Domains Framework","lastPublishedDoi":"10.21203/rs.3.rs-6310946/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6310946/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSmoking in pregnancy has detrimental impacts on maternal and fetal health. The adverse outcomes attributable to smoking however, are reduced if women cease before 20-weeks gestation. Antenatal carbon monoxide (CO) monitoring could provide motivation for smoking behaviour change, but there is limited evidence on pregnant women\u0026rsquo;s perceptions of this intervention.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWomen (n\u0026thinsp;=\u0026thinsp;13) who smoked tobacco during pregnancy were recruited from an Adelaide hospital. They participated in two interviews, 4-weeks apart, using a CO monitor at both. Interviews were audio-recorded, transcribed and thematically analysed using the Theoretical Domains and COM-B frameworks.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis generated two sub-groups highlighting differing framework components: Decreased CO group (DCO, n\u0026thinsp;=\u0026thinsp;7) and Increased CO group (ICO, n\u0026thinsp;=\u0026thinsp;6), as determined by the CO reading at the second interview compared to the first. For both groups, using the CO monitor was understood as an education intervention increasing smoking impact knowledge. The DCO group used this knowledge to increase motivation via intention and goal formation to change smoking behaviour. They reported positive anticipation of repeat monitor use, and increased motivational conditions, reinforcement, optimism and belief about capabilities at the second interview. The ICO group however reported decreased motivation in response to increased knowledge, describing a combination of overwhelming emotional responses and cognitive overload that did not promote behaviour change.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eConsistent CO monitor use may promote smoking decrease through pregnancy for some (only 2 women in the DCO group reported cessation), but not all women, suggesting antenatal CO monitoring should be carefully considered with reference to individual women\u0026rsquo;s needs and circumstances.\u003c/p\u003e\u003ch2\u003eTrial Registration\u003c/h2\u003e \u003cp\u003eRegistered with the Australian New Zealand Clinical Trials (ANZCTR) Registry, Trial ID: ACTRN12621000670875 registered on 02 June 2021.\u003c/p\u003e","manuscriptTitle":"Does use of a carbon monoxide (CO) monitor in pregnancy promote smoking behaviour change? A qualitative exploration using the COM-B framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-14 10:53:50","doi":"10.21203/rs.3.rs-6310946/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-19T14:36:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-29T06:13:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-04T01:20:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"11965050111308971639925121054424427359","date":"2025-05-28T04:43:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"328086893441937805842826195601772580806","date":"2025-05-27T10:32:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245595931712750639628125438089918139741","date":"2025-05-26T23:33:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-19T13:27:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74407328233212726227881515669394450663","date":"2025-05-12T07:59:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-12T04:37:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-28T06:01:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-27T08:06:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T08:04:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-26T09:35:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"104f75ca-4401-4033-8c28-229509d28e2c","owner":[],"postedDate":"May 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T16:38:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-14 10:53:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6310946","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6310946","identity":"rs-6310946","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}