The current study addressed an important gap in the field. To our knowledge, no previous study has developed and evaluated an intervention for pregnant American Indian or Alaska Native women. Because the intervention was targeted and developed with feedback from Y-K Delta pregnant women, it may lack generalizability to other AI/AN women. Nonetheless, our findings on recruitment of pregnant women could inform future intervention development efforts in other Native communities. This evaluation was the next step on our successful 8-year partnership with the YKDRH and addressed an important concern among community members and providers (Enoch & Patten, 2004
). A major strength of our investigation is that the intervention was developed with input and advice from the community. Other strengths are the use of an experimental design, use of theoretically based, well-defined intervention components to enhance replication, and inclusion of quality control procedures.
A key finding was the very low rate of participation suggesting that the program was not feasible or acceptable to pregnant Alaska Native women. Of the 293 women referred to the study, 87% (254) either actively or passively refused to enroll. Reasons reported by women who were screened and decided not to participate were lack of time and not being ready to quit using tobacco. Among women who did not keep their appointment with the study coordinator, anecdotal feedback indicated that the social stigma of tobacco use during pregnancy was a major enrollment barrier. The clinical cessation program was located in front of a large waiting area within the hospital, which could have deterred some women concerned about the social implications of using tobacco during pregnancy. The method by which women were referred to the study may have also played a role. As part of the prenatal care encounter, women were asked if they were interested in participating in a study to help them quit tobacco after being advised of the risks of tobacco use for the mother and fetus. It is possible that in this context, social desirability influences or perceived pressure to participate from a provider who was not from the local community may have played a role.
The perception that Iqmik is safer to use during pregnancy than other forms of tobacco (Renner et al., 2004
) may have also presented a barrier to participation and quitting among enrolled participants. Our focus group work suggested that Alaska Native people are aware of the risks of cigarette smoking during pregnancy but there is a lack of awareness of the harmful effects of Iqmik use (Renner et al., 2004
). Accordingly, the proportion of our participants reporting home bans on chewing was much less than for bans on smoking (15% vs. 88%, ). The primary change for future interventions recommended by our participants was to provide more objective information on the risks of Iqmik use for the baby. Among women from this region of Alaska, pregnancy appears to be a high-risk period in which use of Iqmik and other ST increases dramatically compared with before pregnancy (Kim, England, Dietz, Morrow, Perham-Hester, 2009b
; Patten, Renner, et al., 2008
). In one study (Patten, Renner et al.), there were 432 women who did not use any tobacco in the 3 months before pregnancy of which 323 (75%) reported tobacco use during pregnancy. The majority (78%) of these women reported exclusive use of ST during pregnancy. This may be due to cultural reasons that need exploration in future qualitative studies. In particular, assessment of the cultural beliefs surrounding Iqmik use during pregnancy may inform future intervention efforts.
Additional qualitative work could also determine the best timing for enrolling women in cessation services within the context of pregnancy. Our intervention targeted women who were planning a quit attempt. It may be useful to interview women who are not ready to quit to learn what would attract them to a cessation program and what types of objective information on Iqmik (i.e., biomarker feedback on fetal tobacco-specific carcinogen exposure) would motivate them to quit tobacco. In addition, women’s preconceptions about research should be explored.
Unfortunately, the low participation rate did not allow for adequate testing of the intervention with respect to tobacco abstinence outcomes. While the abstinence rates were very low, the majority (82%) did report ≥1 quit attempt. The low abstinence rates could be attributed to social and demographic characteristics of our sample previously shown to be associated with continued tobacco use during pregnancy such as low income and high parity (Adams, Melvin, & Raskind-Hood, 2008
; J. A. Martin, Kung, et al., 2008
), nicotine addiction, extensive social–environmental cues to use tobacco, and/or cultural influences. The control group intervention was consistent with recommended best practices for pregnant women (Fiore et al., 2008
). However, a limitation of our study design is that the treatment groups were not equated for counselor contact time. Future evaluation studies should include a control group that is balanced for contact time.
Most pregnant women who used tobacco in this region of Alaska were not reached by our recruitment methods and the intervention did not appear to be successful among women who did enroll. Continued efforts to reduce tobacco use among pregnant women are an essential component of a regional plan to significantly improve maternal and infant health (Enoch & Patten, 2004), but it is clear that alternative approaches are needed. We recommend additional qualitative work to explore options for attracting women to cessation programs and cultural beliefs surrounding tobacco use during pregnancy. To reduce the perceived stigma of tobacco use as an enrollment barrier, future studies could consider lifestyle or multiple risk behavior interventions that address issues faced by pregnant women such as stress, physical inactivity, depression, and/or child rearing (Katz et al., 2008
; Prochaska, Spring, & Nigg, 2008
). Research could explore recruitment of women at the time of the pregnancy test that is done by village-based health aides as a means to reach women earlier in their pregnancy. A positive pregnancy test could be an opportune time to offer a healthy lifestyle intervention for women irrespective of their tobacco use. This could help to destigmatize tobacco use to increase enrollment among tobacco users and possibly help to prevent initiation of tobacco use during pregnancy among nonusers. There are also opportunities to utilize elders and other local community members to promote tobacco cessation (Burhansstipanov, Dignan, Wound, Tenney, & Vigil, 2000
). In addition, tobacco control efforts targeting the entire community, not just pregnant women, may yield greater reductions during pregnancy.