7 12 19 20 Overt censure from strangers who do not condone smoking during pregnancy may also trigger strong guilt that stimulates either quit never attempts or reactance, or both.17 20 Women unable or unwilling to quit may rationalise their continued smoking by discounting the risks they face or asserting their invulnerability to these.25 27 28 For example, they may interpret their own perceived well-being as a sign they do not face the risks others face, while the apparent health of other smokers’ babies may reinforce beliefs that smoking is not inevitably harmful.22 27 However, while these approaches might counter cognitive dissonance, affective

dissonance may be less easily resolved. Arousal of negative emotions such as shock, horror and fear could increase the affective element of risk perception, reduce feelings of immunity, and heighten the urgency of behaviour change.29 Research to date suggests cessation messages that elicit strong emotional reactions provoke fewer counter-arguments

than more informational approaches,30 and have stronger effects on lower socioeconomic smokers, where smoking prevalence is higher.29 31 We used this emotion-dissonance framework to explore how women who are pregnant and smoking (or who gave birth within the past year and smoked while pregnant) resolve the tensions they face. Specifically, we sought to identify messages that would promote smoke-free behaviour during and following pregnancy. We began by exploring the metaphors participants used to interpret smoking and quitting. Next, we translated these metaphors into cessation messages that included strong negative affect-arousing themes as well as more informational

approaches, and explored responses to these. Specifically, we addressed the following research questions: RQ1: What metaphors do pregnant smokers use to interpret smoking and quitting? RQ2: How do women who are pregnant and smoking interpret and respond to cessation messages that challenge these metaphors AV-951 and the rationalizations they support? Methods Phase 1 involved in-depth interviews with 13 pregnant women and/or women who had given birth within the past year. In-depth interviews recognised the stigma associated with smoking during pregnancy and so provided participants with privacy. In addition, this approach allows detailed probing of responses, which was important to test interpretations of the alternative messages tested. The second phase comprised in-depth interviews with a new sample of 22 women. For both phases, we recruited a convenience volunteer sample using community advertising, via affinity groups, and through advertising at an antenatal clinic.