Original Article Journal of Addictions Nursing & Volume 24 & Number 3, 149Y157 & Copyright B 2013 International Nurses Society on Addictions

Smoking Motives, Quitting Motives, and Opinions About Smoking Cessation Support Among Expectant or New Fathers John W. Kayser, RN, PhD Candidate m Sonia Semenic, RN, PhD

Abstract Objective: The aims of this study were to identify smoking and quitting motives among expectant or new fathers who were in the precontemplation or contemplation stage of smoking cessation and to explore their perceptions of smoking cessation interventions. Design: This study used a descriptive qualitative design. Setting: The study was conducted in an outpatient antenatal clinic and postpartum unit of a large university hospital. Participants: A convenience sample of five expectant fathers and five new fathers who smoked was used. Method: Qualitative thematic analysis was used to analyze the transcripts of audio-recorded interviews. Results: Despite their reluctance to quit smoking, all the participants made changes in their smoking behaviors during pregnancy or postpartum to protect their partners and infants from the odor and/or potential harm of secondhand and thirdhand smoke. Our findings reveal that pregnancy and childbirth may be a time when men experience additional and unique stress that influences continued smoking but may also give rise to unique motives for future smoking reduction and cessation among men previously resistant to quitting. Furthermore, expectant or new fathers may be more drawn to smoking cessation interventions that foster their own personal strategies to reduce or quit smoking and that respect their needs for self-reliance and control. Conclusion: The perinatal period may be an opportune time for a motivationally based proactive smoking cessation intervention among male smokers.

John W. Kayser, RN, PhD Candidate at the Faculty of Nursing Sciences, University of Montreal, Que´bec, Canada. Sonia Semenic, RN, PhD, Associate Professor at the Ingram School of Nursing, McGill University, Montreal, Que´bec, Canada. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. Correspondence related to content to: John W. Kayser, RN, PhD Candidate, 5000 rue Be´langer, Bureau S-2490, Montre´al, Que´bec, Canada, H1T 1C8. E-mail: [email protected] DOI: 10.1097/JAN.0b013e3182a4caf1 Journal of Addictions Nursing

Keywords: ambivalence, motivational interviewing, secondhand smoke, smoking fathers, stages of change, thirdhand smoke

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espite steadily decreasing smoking rates in North America (Centers for Disease Control and Prevention, 2011; Health Canada, 2011), cigarette smoking and exposure to secondhand smoke (SHS) remain as important modifiable risk factors for adverse perinatal outcomes (Dietz et al., 2010). Paternal smoking is the most common source of nonmaternal household SHS (Blackburn et al., 2005) and is one of the strongest predictors of continued maternal smoking during pregnancy and/or postpartum smoking relapse (Ingall & Cropley, 2010; Severson, Andrews, Lichtenstein, Wall, & Zoref, 1995; Wakefield & Jones, 1998). Whereas the perinatal risks associated with maternal smoking are well documented (Al-Sahab, Saqib, Hauser, & Tamim, 2010), paternal smoking is also associated with several neonatal complications (Leonardi-Bee, Smyth, Britton, & Coleman, 2008). Infants exposed to SHS are at further risks for sudden infant death syndrome (Jones et al., 2011; Treyster & Gitterman, 2011), and emerging evidence also suggests that infants may be affected by the carcinogens produced by ‘‘thirdhand smoke’’ (THS; Petrick, Svidovsky, & Dubowski, 2011; Rehan, Sakurai, & Torday, 2011; Sleiman et al., 2010). THS is the tobacco smoke contaminants found on surfaces such as skin, hair, clothes, and household upholstery and in house dust (Matt et al., 2011; Winickoff et al., 2009). Whereas to date, literature on tobacco use during the perinatal period has focused primarily on maternal smoking cessation, literature related to paternal smoking remains scant (Gage, Everett, & Bullock, 2007; Winickoff et al., 2010). In women, pregnancy has long been recognized as an opportune moment for smoking cessation because of such motives as the desire to protect the fetus and infant, increased social pressures to abstain from smoking, enhanced contact with health professionals, and pregnancy-induced aversion to the taste and smell of cigarettes (McBride, Emmons, & Lipkus, 2003; Pletsch & Kratz, 2004). Consequently, up to 45% of pregnant smokers manage to quit smoking on their own (Lumley et al., 2009). A few studies suggest that pregnancy and childbirth may also be www.journalofaddictionsnursing.com

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a ‘‘teachable moment’’ for smoking cessation among expectant or new fathers because of heightened awareness of the negative health impact of their smoking (Gage et al., 2007; Pollak et al., 2010), leading to positive changes in their smoking behaviors (Brenner & Mielck, 1993; Hyssala, Rautava, Sillanpaa, & Tuominen, 1992; Kaneko et al., 2008); however, one U.S. study found that 80% of low-income expectant fathers who smoked were in the precontemplation or contemplation stage of smoking cessation (Everett et al., 2005), underscoring the challenges of addressing male-partner smoking during the perinatal period. Precontemplation and contemplation are the two stages of change that occur before a smoker makes a serious commitment to quit smoking (Prochaska, Diclemente, & Norcross, 1992). Compared with smokers who are preparing or attempting to quit, smokers in the precontemplation or contemplation stages tend to be more reluctant to quit smoking, express more motives toward continued smoking and fewer motives for quitting, and are less willing to seek smoking cessation support (DiClemente et al., 1991; Prochaska & Goldstein, 1991). Ambivalence, proposed as a central characteristic that explains why smokers get ‘‘stuck’’ in the precontemplation or contemplation stage (Miller & Rollnick, 2002), is defined as a state of psychological conflict involving the competing motives of the costs of continued smoking and benefits of quitting (i.e., quitting motives) versus the benefits of continued smoking and costs of quitting (i.e., smoking motives). Motivational interviewing (MI) is an effective smoking cessation counseling intervention (Hettema & Hendricks, 2010) that aims to enhance motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2002). Presenting smokers with personalized normative feedback, such as expired carbon monoxide (CO) levels, is one particular strategy often used in combination within an MI intervention for smoking cessation that may be well suited for more resistant smokers (Butler, Rollnick, Bachmann, Russell, & Stott, 1999; Hettema & Hendricks, 2010). Although few intervention studies to date tailored to expectant or new fathers have shown limited but promising effects in increasing smoking cessation rates compared with usual care (Duckworth & Chertok, 2012; Gage et al., 2007), none was tailored to the unique smoking motives (i.e., the benefits of smoking and costs of quitting) and quitting motives (i.e., the costs of smoking and benefits of quitting) found in smoking expectant or new fathers. To tailor effective smoking cessation interventions such as MI to men during the perinatal period, it is essential to better understand the unique smoking motives and quitting motives that may contribute to ambivalence related to smoking cessation. Few studies to date have explored barriers or motivators related to smoking cessation among expectant or new fathers, and none explored within the framework of examining ambivalence in those more reluctant to quit. An exploration of perceived barriers to smoking cessation among 32 smoking expectant fathers who attended their pregnant partners’ routine antenatal visit found that, although the men felt strongly about not smoking around the newborn infant, they were less 150

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worried about the effects of SHS exposure during pregnancy and were concerned that withdrawal symptoms associated with attempting to quit smoking would potentially increase interpersonal conflict with their pregnant partners (Wakefield, Reid, Roberts, Mullins, & Gillies, 1998). Similarly, in an ethnographic study that included 29 new fathers who had smoked during pregnancy, Bottorff and colleagues found that smoking was an integral part of men’s masculine identity, which helped to maintain their emotional stability (Bottorff, Oliffe, Kalaw, Carey, & Mroz, 2006). Furthermore, continued smoking was triggered by social smoking at work and work-related stress and as a need for a reward and as a way to cope with boredom (Bottorff et al., 2006; Oliffe, Bottorff, Johnson, Kelly, & Lebeau, 2010). Conversely, motives for smoking cessation among the fathers who had quit smoking, reduced smoking, or intended to quit smoking in the near future included providing a smokefree home for the new baby, improved personal health, physical performance enhancement, smoke-free role modeling for their children (particularly once the children become older), and financial burden of continued smoking (Bottorff, Radsma, Kelly, & Oliffe, 2009). To explore the feasibility of addressing smoking among expectant or new fathers who are not actively engaged in smoking reduction or cessation and may not yet be intending to quit, more information is needed about their general opinions and attitudes related to smoking cessation support. One potential strategy for gaining access to smoking men during the perinatal period may be to opportunistically engage them in brief smoking cessation interventions while they accompany their partners to prenatal visits or during the postpartum hospital stay. Therefore, the purposes of this pilot study were to identify smoking and quitting motives among expectant or new fathers who were in the precontemplation or contemplation stage of smoking cessation and to explore their perceptions of smoking cessation interventions. The primary research questions for this project included the following: (1) ‘‘What changes have the new or expectant fathers observed, if any, in their smoking behavior since their partners’ pregnancy?’’, (2) ‘‘What motivates them to continue smoking at the present time?’’, and (3) ‘‘What might motivate them to think about or commit reducing or quitting smoking in the future?’’ Secondary questions explored new or expectant fathers’ opinions of smoking cessation support, including the acceptability of proactively addressing smoking among male partners during routine prenatal or postpartum care. METHOD This study used a descriptive qualitative design (Sandelowski, 2000) using in-depth individual interviews guided by a semistructured interview guide (see Table 1). Participants and Setting After obtaining institutional ethics approval for the study, a convenience sample of 10 men who smoked was recruited through the outpatient antenatal obstetrical clinic (n = 5 expectant fathers) and the in-hospital postpartum unit (n = 5 July/September 2013

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TABLE 1

Excerpt from the Semistructured Interview Guide

Primary Questions Changes in smoking behaviors 1. What changes have you observed in your smoking behavior since your partner’s pregnancy? Smoking motives: Benefits of smoking and costs of quitting 2. Now that you are expecting a baby (or expecting to care for the new baby), what motivates you to continue smoking right now? & What has prevented you until now to let it go completely (i.e., quitting smoking)? Quitting motives: Costs of smoking, benefits of quitting, and ability to quit 3. Now that you are expecting a baby (or expecting to care for the new baby), what might motivate you to think about reducing or quitting smoking? & What might you need to do to manage smoking less or not smoking if you decided to do this right now? Secondary Questions Opinions about smoking cessation support 4. What kind of support do you think new or expectant fathers that smoke would find most helpful for quitting smoking (cutting down)? Reactions to interview and normative feedback 5. What do you think about being asked, during your partner’s routine perinatal visit (or postpartum care), about what motivates you to smoke and quit smoking? 6. After administering the FTND questionnaire and CO test and having explained the results: & What went through your mind as I explained the results of these measures?

new fathers) of a large university hospital in Que´bec during the fall of 2009. The inclusion criteria were (a) reported daily smoking, (b) having been classified in either the precontemplation or contemplation stage of smoking cessation, (c) spoke and read French or English, and (d) lived in the same household as their partner. To meet inclusion criterion (b), a single self-report question that categorized smokers into either the precontemplation or contemplation stage was posed verbally: ‘‘Have you made a firm decision to quit smoking in the next thirty days?’’ Those answering ‘‘no’’ met this inclusion criterion (Etter & Perneger, 1999). Candidates were excluded from the study if (a) they or their partners were currently experiencing severe social or psychiatric problems, (b) their newborn had severe congenital abnormalities, or (c) the mother was experiencing a complicated pregnancy. Study participants were recruited while they accompanied their female partners to a prenatal clinic visit or during the postpartum hospital stay. Participants were identified and Journal of Addictions Nursing

approached about the study by the hospital’s perinatal smoking cessation nurse, who routinely collected data on fathers’ smoking status as part of the hospital’s perinatal smoking cessation program. The first author (who was readily available on site) then met with interested participants to confirm their eligibility, explain the study procedures, and obtain signed consent. The face-to-face interviews with the participants took place alone with the first author in a private room immediately after recruitment. After the interview, participants completed a short questionnaire to collect data on participants’ sociodemogaphics and smoking behaviors, a brief self-report measure of nicotine dependency, and a physiological measure of expired CO. All participants were compensated $25.00 for any inconvenience (e.g., extra parking time) incurred as a result of their study participation. Measures The Fagerstro¨m Test for Nicotine Dependence (FTND) and measures of expired CO were used to collect data on smoking characteristics and to explore participants’ opinions about receiving normative feedback about their smoking. The FTND (Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991) is a brief, six-item validated measure that scores levels of nicotine dependency from very low (0Y2), low (3Y4), moderate (5), high (6Y7), to very high (8Y10; Meneses-Gaya, Zuardi, Loureiro, & Crippa, 2009). A CO monitor was used to provide an instant breathalyzer measurement of the participants’ alveolar CO level in parts-per-million (ppm) of expired air. Results less than 6 ppm can be considered to be nonsmoking status (Christenhusz et al., 2007). Data Analysis Content analysis was used to analyze the qualitative data (Polit & Beck, 2012). Open coding was used to code the individual transcripts (Carpenter, 2007). These codes evolved using constant comparison (Thorne, 2000). The codes were then collapsed into broader categories, which were then categorized into themes (Burnard, Gill, Stewart, Treasure, & Chadwick, 2008). Themes were grouped according to the study questions, and new themes emerged during the coding process. The two authors met regularly during the data analysis process to discuss and validate emerging codes and themes. Descriptive statistics were used to analyze the quantitative data obtained from the FTND, CO test, participant demographics, and smoking characteristics. RESULTS Participant Characteristics Participants’ demographic and smoking characteristics are presented in Table 2. Most of the fathers did not complete university, had a household income of less than 50,000/year, worked full-time, and were living with a nonsmoking partner. The smoking characteristics revealed a mean (SD) of 13.6 (7.3) years smoked and of 5.9 (6.2) quit attempts over their lifetime. In lighter smokers, smoking less than 10 cigarettes per day (six www.journalofaddictionsnursing.com

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TABLE 2

Demographics and Smoking Characteristics of Interviewed Participants

Demographics and Smoking Characteristics Age (M T SD)

n = 10 31.1 T 5.7

Education High school (%)

40.0

Preuniversity (%)

20.0

University (%)

40.0

Household income per year in thousands 10Y29 (%)

50.0

30Y49 (%)

20.0

50Y79 (%)

10.0

100Y119 (%)

20.0

Full-time work (% yes)

80.0

Smoking partner (% yes)

20.0

Self-reported cigarettes smoked per day (M T SD)

11.0 T 9.9

Expired alveolar carbon monoxide (ppm; M T SD)

14.0 T 10.7

Fagerstro¨m Test for Nicotine Dependence (M T SD) Number of years smoked (M T SD) Number of lifetime quit attempts (M T SD)

3.9 T 2.5 13.6 T 7.3 5.9 T 6.2

Note. Expired alveolar carbon monoxide measured (less than six parts-per-million [ppm] is considered nonsmoking status). Fagerstro¨m Test for Nicotine Dependence: very low = 0Y2; low = 3Y4; moderate = 5; high = 6Y7; very high = 8Y10. SD = standard deviation.

fathers), the mean (SD) CO was 6.3 (4.4) ppm. In heavier smokers, smoking ranged from 15 to 30 cigarettes per day (four fathers), the mean (SD) CO was 25.5 (4.4) ppm. The FTND ranged from ‘‘very low’’ in the lightest smokers to ‘‘high’’ in the heaviest smokers. The mean (SD) interview length was 46 (19.3) minutes. Changes in Smoking Behaviors All participants were smoking exclusively outside of their homes at the time of the interview. Half began smoking outside as soon as they knew their partner was pregnant, four already smoked outside before the pregnancy, and one smoked outside his home more frequently after learning about his partner’s pregnancy and then decided to smoke exclusively outside 4 days before his child’s birth. As one father described, ‘‘Iduring the pregnancy, what I thought is I am not smoking in front of her. I’m just keeping her away whenever I smoke so that she cannot breathe the smoke. I’ll go outside to smoke...so that there is no chance of getting the smoke into the house.’’ 152

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Another marked change in behavior during pregnancy reported by five participants was an increased effort to eliminate personal cigarette odor before coming into contact with their partner. Strategies used by the participants to eliminate cigarette odor included brushing their teeth, chewing gum, changing their clothes, and washing their hands and face after smoking. Whereas five participants reported that the extra efforts involved in smoking outside and/or eliminating personal cigarette odor inadvertently led to a reduction in smoking, two participants reported an increase in their smoking during their spouse’s pregnancy, and three reported no change in cigarette smoking consumption. When the participants were asked what motivated them to smoke outside and/or remove cigarette odor during pregnancy, two main themes emerged: (1) protecting their partners from cigarette odor and (2) protecting the fetus and baby-to-be from harm. Protecting Their Partners From Cigarette Odor Six participants conveyed that their partners were more sensitive to the odor of SHS and THS during pregnancy. One participant described his partner’s negative reaction to SHS odor: ‘‘She said, ‘When I smell it, I feel nauseaIwhenever I smell smoke here I feel like I want to throw up...’ So, I try to respect that.’’ Three participants expressed how their partners’ repulsion to THS odor negatively affected the couple’s intimacy. One father noted, ‘‘I cannot kiss her without brushing my teeth. It’s disgusting for her. She won’t kiss meVlogical stuff.’’ Another participant who was hiding his smoking from his partner expressed his frustration with the difficulty of eliminating the odor of cigarettes: Ithere’s an awareness obviously because she has heightened senses. So even though I quit smoking, she still knows that I’m smoking, or I’m having occasional cigarettes. And even with multiple attempts to try and mask the smell, she can still smell it. So I can’t really hide it, or I gotta really scrub hard to get the smell out. Protecting the Fetus and Baby From Harm Seven participants reported that another reason for them to smoke outside during pregnancy was to protect the fetus and newborn from the potential physical harms of SHS and THS. Three expressed their views about the potential fetal harm from SHS exposure. One said, ‘‘First hand smoke is filtered [via the cigarette filter] and the SHS isn’tIso the worst is the SHS because nothing is filtered for him [the fetus],’’ and another said, ‘‘God forbid if he had a defect because I smoked, or something.’’ Five spoke of the potential harm to a newborn caused by SHS. For example, one described how SHS is not good for the baby’s fragile lungs, developing brain, and growth. Another expressed, ‘‘Imy wife can leave the room if she wants to, if really I would smoke. He (his new baby) can’t do anything, the poor kidIit would be a hundred percent my fault.’’ Concerns about the potential harm of THS on their babyto-be were expressed by two participants. For example, one conveyed the following new realization about THS: July/September 2013

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I haven’t realized until since recentlyII finished smoking, just breathing in and breathing out those chemicals and by-products. I always thought, ‘‘Ok, you breathe them in and breathe them out, and they’re gone.’’ But in reality, they still linger, they’re still in you and you breathe them out onto the baby, onto the childIwhen you go to the newborn, you know that they’re fragile and they’re spotlessVclean inside and outVyou may contaminate them. Smoking and Quitting Motives Smoking Motives When participants were asked what motivated them to continue smoking, three main themes emerged: (1) smoking triggers, (2) stress/emotional states, and (3) addiction (see Table 3). Smoking triggers The participants described a variety of situations where their smoking occurred automatically in association with external cues. All the participants reported smoking triggers related to daily habits/routines, social situations, or a combination of both. A typical combination of

TABLE 3

Elaborated Themes Under the Category ‘‘Smoking Motives’’

Theme

Description

Smoking triggers

Habit and routine

Examples -After waking up, work, meals, sex, and before bed -With coffee and alcoholic drinks

Social

-When seeing others smoke and being offered cigarettes from strangers, family, and friends

Combined

-Multiple habit, routine, and social triggers combined

Stress/emotional states

-When excited, happy, sad, tired, bored, anxious, or worried -Work-related conflicts -Partners’ labile moods leading to conflict; preparing for birth leading to worry

Addiction

-Calming, relaxing, energizing, rewarding, or pleasurable -More irritable within the first month, and fear of living with continuous craving -Fear of being impatient or aggressive toward others

Journal of Addictions Nursing

smoking triggers was illustrated in the following quote: ‘‘Igo to a nice cafe, beautiful sunny day outside, chilling at a terrace, having a beer or a coffee. Within two hours, I’m going to have at least six, seven cigarettes.’’ Stress/emotional states Smoking to help regulate stress or other emotional states was identified by 9 of the 10 participants. Although the sources of stress and the type of emotions were varied, five participants reported smoking in response to sources of stress uniquely related to pregnancy: (1) the extra demands of preparation for fatherhood and (2) couple discord as a result of the female partners’ mood swings. For example, one participant attributed his increase in smoking to the stress experienced by the extra demands from expecting a newborn: ‘‘I was happy [when hearing about the pregnancy] but all of a sudden the stress comes in: You have to prepare for the baby, you have to buy things, and you have to do everythingII just started smoking more.’’ Smoking in response to the female partners’ mood swings was illustrated by the following quote: ‘‘II would smoke less but sometimes a pregnant woman has very highs and very lows, so her character can be weird and unexpectedVsometimes friction could be caused. So, I go outside and I could maybe smoke two.’’ Another described his smoking as ‘‘Ithe excuse to get out of the house,’’ in response to the ‘‘Ihormonal changes in women,’’ and another described how smoking helped him communicate better with his partner: ‘‘I would argue with my wife, but I would just go outside for a cigarette, and maybe two minutes after, I come in and I’ll be more calm. It helps you be even more reasonable and it improves your communication skills.’’ Addiction Nine participants described experiences that exemplified being physically addicted to their smoking, with four stating clearly that ‘‘it’s an addiction.’’ These experiences were related to situations where there were perceived benefits, desire, or need to smoke as well as perceived costs of not smoking. One participant noted a benefit: ‘‘Iit gives me that two-three minutes to be in another zone’’; another described his need to smoke: ‘‘There’s something inside of me that tells me to smoke’’; and others explained how they felt irritable when not smokingVa few fearing continued craving if they quit smoking completely. Quitting Motives When the new or expectant fathers were asked what might potentially motivate them to think about reducing or quitting smoking at this point in their lives, five themes emerged: (1) improved health, (2) being there, (3) role modeling, (4) time with baby, and (5) saving money. Improved health Six participants reported feeling adverse health effects from their smoking and/or described health benefits they had experienced during past attempts to quit or reduce smoking (see Table 4). Frequently reported costs of continued smoking were feeling out of shape and future fear of chronic illness. Frequently reported were gains in physical stamina from quitting and their belief that a life without cigarettes meant having more energy. Being there Most participants reported that they would be motivated to quit smoking if it meant avoiding fatal or morbid www.journalofaddictionsnursing.com

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TABLE 4

Elaborated Theme ‘‘Improved Health’’ Under the Category ‘‘Quitting Motives’’

Health Costs of Continued Smoking

Future Health Benefits of Reducing or Quitting Smoking

Current

-Gain more stamina for:

-Bad for health

& Exercise

-Feel out of shape

& Walking

-Morning cough, short of breath, chest pain

& Sex

-Headaches

-Cough and headaches go away

-Depressed after smoking

-Breathing improves

-Discolored teeth and fingers

-Will feel good, alive, fresh, and euphoric

Future -Fear of cancer -Bad for lungs, asthma, and the heart -May get sick quicker, and the body does not heal as well if sick

health consequences related to continued smoking. However, five made the explicit link that their desire to remain alive and healthy was heightened by their new will to participate in and witness their child’s developmental milestones. One father said that his motivation to avoid health consequences from smoking was for his baby-to-be: ‘‘Health is for the long term. Later on, when olderIyour lungs, you get sick quicker. Your body is not as able to heal. No, I do not see myself at 60 years old with a cigarette in my mouth. I do this all for herVI do it (eventually quitting smoking) for my daughter (new born).’’ Another explained further why avoiding illness was important to him: ‘‘My son, he needs me. If you would tell me to quit, I’d probably quit for him. He (his newborn son) will depend on me for many different things and I would obviously like to be there through all the stages of his life: growing up, going to school, getting married one day.’’ Role modeling Four participants added that they would quit, reduce, or hide their smoking to be a good role model for their child. For example, one said, ‘‘Iit is hard being a role model for something you are doing wrong,’’ and another noted, ‘‘II am telling him not to do itVthe kid is not stupid.’’ One participant reasoned that role modeling smoking would give his child a reason to start smoking in the future. He stated: ‘‘No, I would never smoke in front of him [his child-to-be]. Because, even if I do it, he could do it tomorrow and say: ‘Oh Dad, you used to do that.’’’ Another concern expressed was when their child-to-be becomes old enough to notice and ask questions: ‘‘Ihe is 3 or 4 years old and he asks questions like: ‘What is that? What is this?’’’ or tell the father directly to quit, ‘‘Iif my kids will say ‘Daddy, don’t do that (smoke),’ I will (quit).’’ 154

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Time with baby Four participants reported that time spent with their baby-to-be may influence further change in their smoking behavior. For one participant, it meant that there would be less time to smoke: ‘‘You have to make time to smoke now. You can’t just light up while you are feeding her, not while you are driving her somewhere.’’ Another realized during the interview: ‘‘Instead of trying to run out and have a cigarette and finding an excuse to run out, I’d be with the child. Wow.’’ Saving money Four reported that quitting smoking would help save moneyVtwo of them noted saving money for the baby. One participant concluded: ‘‘More money for the baby, more money for myself, and more money.’’

Opinions About Smoking Cessation Support When asked their opinions about what kind of support they would find helpful to reduce or quit smoking if they ever decided to change their smoking behaviors, most participants indicated preferring to quit on their own rather than to seek professional support. One said, ‘‘Once I put my mind on something, I’m very focused on it. I’m very strong minded. If I want something, I’m going to get it. If I want to do something, I’m going to do it.’’ In addition, all participants described personal strategies that would help them reduce or quit smoking in the future. The strategies reported by the participants were grouped into the following categories and summarized in Table 5: (1) avoiding triggers, (2) substitution, (3) distraction, (4) reducing, (5) waiting, (6) social support, (7) physical exercise, (8) and self-talk. TABLE 5

Participants’ Reported Strategies to Help Reduce or Quit Smoking

Strategies Avoiding triggers

Examples Avoiding others who smoke. Reducing alcohol and coffee consumption.

Substitution

Finding something else to do instead of smoking.

Distraction

Playing a video game, watching soccer on TV, eating, or thinking of something else.

Reducing

‘‘I smoke seven: I’m going to do six, five, four, three, two, one, one, one, one, oneVand then, that’s it!’’

Waiting

Waiting the craving out while in a nonsmoking area. Analyzing the need to smoke to delay the next cigarette.

Social support

Quitting together with partner. Talking to somebody (partner, family, or friend) instead of smoking.

Physical exercise

Exercising at the gym, jogging, running, biking, or walking.

Self-talk

Using self-talk, e.g., ‘‘I will do it.’’ July/September 2013

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Reactions to Interview and Normative Feedback Participants were asked how they felt about being asked, during their partners’ routine perinatal visit (or postpartum care), to reflect on their smoking and quitting motives. Nine participants reported that this style of interview (i.e., exploring smoking and quitting motives) would be acceptable to them as part of their partner’s prenatal visits or during postpartum. Seven participants described the interview process using positive words such as enjoyable, motivating, encouraging, supportive, not too pushy, and could build confidence to quit smoking. One participant said: ‘‘It’s goodIvery good. I mean, I’m taking the time and trying to understand why, how to quit smoking and the benefit of quitting,Iyou sit down, you’re taking time to talk to the person, it’s a good thing.’’ Another said, ‘‘Igood format, I mean it’s not too pushyVbetter than medical advice.’’ Their reactions to the normative feedback, the results of the expired CO and FTND, were all positiveV‘‘It’s motivating,’’ as one stated. Another said, ‘‘Stuff like this works, this 24 [his CO result]...because not that it scares you, but shows me like you’re seeing that I’m more than doubleIthe first thing that came to my mind was that ‘I gotta quit.’’’ Others echoed the same need to quit or reduce after the tests results. In addition, one reported: ‘‘Showing your patient facts with numbers, tests, questionnaires, and machinesVI think you have a better impact.’’

DISCUSSION The results of this study highlight the competing motives for smoking and quitting among expectant or new fathers in the precontemplation or contemplation stage of smoking cessation. Although none of the 10 participants were intending to quit smoking, all had ceased smoking indoors by the beginning of their partner’s pregnancy, and half had reduced their cigarette consumption. Our findings revealed that the men smoked outdoors primarily in acknowledgment and respect of their pregnant partners’ enhanced aversion to SHS, which in turn affected the couples’ intimacy, further motivating the participants to engage in additional actions to mask or eliminate the smell of cigarettes. Although most of the participants in this study made positive changes to their smoking behaviors during their partners’ pregnancy, they identified numerous motives for continuing to smoke. Pregnancy and childbirth is acknowledged as a time when men may experience additional and unique stress (Buist, Morse, & Durkin, 2003; Deave & Johnson, 2008), and the transition to fatherhood has been described as a profound psychological process that involves feelings of anticipation about their new paternal role before birth, feelings of helplessness at the time of birth, and a reorganization of their lifestyle after birth (Genesoni & Tallandini, 2009). Our study corroborated Wakefield et al.’s (1998) findings that one potential source of stress related to male smoking during pregnancy was spousal conflict influenced by the partner’s labile moods. In addition, our findings suggested that the pressure new or expectant fathers feel from the extra deJournal of Addictions Nursing

mands of preparing for birth may be an additional motive for them to maintain or increase their smoking. Whereas the stress related to the transition to fatherhood may motivate continued smoking, the transition to fatherhood may also motivate men to make positive changes in their lifestyle. Young fathers who were involved in delinquent behaviors before birth expressed fatherhood-related motives including the desire to protect their children, saving more money for their families, leading more responsible lives, and making healthier lifestyle choices (Reeves, 2006). Although the desire to role model nonsmoking behavior, additional time spent with the baby, and saving money for the baby were important motivators for smoking cessation found in previous studies (Bottorff et al., 2006, 2009), we found an additional motive in their expressed desire to witness and participate in their child’s developmental milestones. The participants in our study expressed reluctance to consider formal forms of smoking cessation help and preferred to reduce or quit on their own time and in their own way. This was not surprising as our sample were smokers not intending to quit in the near future. However, it is well known that men have a greater tendency to avoid health help-seeking than women (Galdas, Cheater, & Marshall, 2005), and evidence suggests a general reluctance among men to seek support for smoking cessation (Kairouz et al., 2007). The masculine gender-role socialization paradigm may provide a better understanding of men’s reluctance to seek help for healthrelated issues (Addis & Mahalik, 2003). This theory posits that men avoid seeking help because doing so may be in conflict with their own assumptions about masculinity, which include self-reliance, physical toughness, and emotional control. The fathers in our study reported a varied list of concrete strategies that they would potentially follow for future smoking cessation attempts despite their current lack of readiness to quit or seek help for smoking cessation. New or expectant fathers in the precontemplation or contemplation stage may be more drawn to smoking cessation interventions that foster their own personal strategies for future smoking reduction or quitting and interventions that respect their needs for self-reliance and control. Nursing Implications This study supports previous literature that suggests pregnancy is an opportune time to intervene with both maternal and paternal smoking. Past literature supports prenatal education on smoking (Duckworth & Chertok, 2012), and our findings support the acceptability of adding information about THS into these interventions. Although fathers may be more motivated for smoking cessation after their baby is born (Brenner & Mielck, 1993; Winickoff et al., 2010), our study lends further support to the acceptability of proactively delivering brief smoking cessation interventions to smoking fathers during their partners’ routine prenatal and postpartum care. Although limited because of our small sample size and selection bias, the participants reacted favorably to the open-ended questions aimed at collecting data about their smoking and quitting www.journalofaddictionsnursing.com

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motives as well as to the results presented to them from the FTND and CO tests. MI combined with normative feedback is an evocative approach that respects clients’ autonomy in their decision and in their personal preferences in the process of change (Miller & Rollnick, 2002). As MI tends to be conducted as a ‘‘nonformal’’ counseling style, it may be particularly suitable for new or expectant fathers who prefer smoking cessation strategies that foster their sense of self-reliance and control (Addis & Mahalik, 2003; Bottorff et al., 2009). Study Limitations and Future Research Our results are limited because of our use of convenience sampling and our small sample size. Selecting a larger sample from multiple settings may help uncover other salient themes that were not reported in this study. Because the participants were self-selected, a bias may have occurred favoring a recruitment of fathers who may have had more positive views of smoking cessation. Furthermore, this study may have been negatively affected in its ability to truly recruit ‘‘resistant’’ smokers because of lack of a satisfactory method to categorize smokers within a particular stage of change (West, 2005). This study was designed to help inform a future quantitative study that may test the feasibility, acceptability, and smoking cessation outcomes of a personalized MI-based smoking cessation intervention for smoking new or expectant fathers. Thus, future research may focus on testing the effect of a brief, proactive MI-based smoking cessation intervention among smoking new or expectant fathers delivered opportunistically during their female partners’ prenatal or postpartum care. Acknowledgments: This study was supported by a Master’s study grant from the Quebec Interuniversity Nursing Intervention Research Group (GRIISIQ) and the Fonds de la recherche en sante´ du Que´bec (FRSQ). We would like to acknowledge the assistance of Rina Fusco for recruiting the study participants; Margaret Purden for her guidance; and the nurse managers, assistant managers, and staff nurses at the MUHC-Royal Victoria Hospital obstetrical clinic and postpartum unit for their support.

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