Barriers and Enablers to Prescribing Nicotine Replacement Therapy during Pregnancy

Background

Nicotine replacement therapy (NRT) is recommended during pregnancy, when the pregnant woman is unable to quit smoking. A systematic review found that 12.6% of health providers report prescribing NRT ‘always/often’ to pregnant women. The aim was to explore the barriers and enablers to prescribing NRT in pregnancy.

Methods

A mixed methods study, including: 1) a national Australian cross-sectional survey on knowledge, attitudes and practices of general practitioners and obstetricians regarding NRT prescription during pregnancy; Outcome measures included 5-point Likert scales about prescribing rate; and influences including reading guidelines; perceived NRT safety, effectiveness, and adherence; and confidence in ability to prescribe. An ordinal regression was performed for each outcome measure with the dependent variable the prescription rate, adjusted for gender and years of medical experience; 2) a qualitative study exploring the thoughts of general practitioners on prescribing NRT during pregnancy. Purposeful sampling of participants from the above survey was performed. 3) Narrative review of current guidelines from high income countries on the use of NRT during pregnancy.

Results

378 clinicians participated in the survey. 25.1% reported ‘never’ prescribing NRT. Confidence in ability, viewing NRT as safe and effective, and reading guidelines were significantly associated with higher prescription rates. Interviews were conducted with 19 participants. Two themes arose- “need for clear guidance’ and ‘women don’t want to use it’. A total of 8 guidelines were included. Guidelines impose restrictions on prescribing NRT and none offer practical clinical guidance on ‘when’ and ‘how’ to prescribe it.

Discussion

NRT prescription rates during pregnancy are low. Training and clinical protocols may help change clinicians’ views on the ‘harm versus benefit’ and provide practical detail on prescribing NRT effectively. A multi-disciplinary consensus on this topic is needed if women are to receive a consistent approach from care-givers.