“Put that out I can hear your baby coughing”: exploring the stigma associated with women’s smoking during pregnancy

Abstract

Despite comprehensive tobacco control policies in Australia, smoking during pregnancy is still relatively common. Women who continue to smoke during pregnancy report significant guilt, shame, and embarrassment for smoking in the face of widespread messages about the risks to the developing foetus of smoking. Located within critical health psychology and working within a social constructionist framework, this thesis examines the social meanings attached to smoking and addresses their incompatibility with dominant constructions of motherhood, specifically, what it means to be a good mother. The aims of the thesis are twofold: to (1) explore experiences and perceptions of smoking during pregnancy in the Australian context (2) examine the ways in which the presumed stigma attached to smoking during pregnancy is discursively negotiated by both members of the public and women who engage in this practice. This thesis is based on three interconnected projects: 13 semi-structured, short interviews with women who smoked during their recent pregnancies (Study 1); a survey with 626 university students (Study 2); and an online survey with 47 women who smoked during their recent pregnancies (Study 3). Chapter 1 outlines the theoretical framework that underpins this thesis, namely, critical health psychology and social constructionism. This is followed by a discussion of the relevance of reflexivity and a summary of the methodologies of the studies that make up the thesis. Chapter 2 provides a review of the literature relevant to the empirical chapters of this thesis. It covers the tobacco denormalisation movement and the stigmatisation of smokers, particularly in the Australian context, and critiques the limited consideration of gender and the need for a feminist perspective. It then discusses the ways in which the foetus remains a central part of tobacco control campaigns targeting women during pregnancy and the literature examining women’s smoking during pregnancy. Outlining the problems related to a foetal-centred approach to women’s smoking, this chapter explores how the good mother discourse contributes to the stigmatisation of women who smoke during pregnancy. Relevant to the first aim of this thesis, Chapter 3 presents a thematic analysis of 11 interviews with women who smoked during their recent pregnancies (Study 1, excluding the two pilot interviews). It examines women’s experiences and constructions of stigma, with a particular focus on the material consequences of stigma. Building on these findings, Chapter 4 examines the extent to which university students expressed negative views towards women who smoke during pregnancy, drawing on quantitative data provided by 595 university students (Study 2, excluding 31 participants due to high levels of missing data). Together these chapters point to the need to explore alternative, more supportive, approaches to promoting smoking cessation during pregnancy. Reflecting on this ‘evidence’ of stigma concerning women who smoke during pregnancy, Chapter 5 considers the role of the research design in university students’ views (Study 2). It questions the extent to which this ‘evidence’ of stigma (namely, negative text responses provided by university students) was co-created by the research context. This chapter reflects a shift in the methodological approach to data analysis and also the explicitly social constructionist ontology of this thesis. As a result of this reorientation, Chapters 6 and 7 examine the ways in which the presumed stigma attached to smoking during pregnancy is discursively negotiated by women who smoke during pregnancy. Chapter 6 analyses interview data from Study 1 (excluding the email interview) and focuses on how women accounted for their smoking and their identities in the context of a biomedical discourse, which constructs smoking during pregnancy as undoubtedly harmful to the foetus. Chapter 7 draws on three sources of data to examine the available ways for women who smoke during pregnancy to represent themselves: 13 interviews from Study 1; survey data from Study 3; and a media article written by an Australian television and radio host who smoked during pregnancy. This chapter highlights the lack of positive identities offered by anti-smoking and good mother discourses, and how the combination of these discourses works to discursively silence these women’s experiences and render them untellable. In closing, Chapter 8 brings together the empirical, methodological, theoretical and practical contributions of this thesis. This chapter revisits the material and discursive perspectives I have taken in exploring stigma, and how this uniquely impacts women who smoke during pregnancy, to offer a feminist voice in the debate regarding the ethics and effectiveness of stigmatising smokers. Further, I consider future empirical and theoretical directions for work in this area, and discuss the role of reflexivity in shaping the dissemination of this work.