"It's a big conversation": Views of service personnel on systemic barriers to preventing smoking relapse among pregnant and postpartum Aboriginal and Torres Strait Islander women - A qualitative study

Background: Providing smoking cessation care has not successfully prevented women who quit smoking during pregnancy from relapsing due to multi-level barriers. Aim: This paper explores systemic barriers to providing smoking cessation care, focusing on relapse prevention among pregnant and postpartum Aboriginal and Torres Strait Islander women (hereafter Aboriginal). Methods: Twenty-six interviews were conducted between October 2020 and July 2021 with health professionals, health promotion workers and managers working in Aboriginal smoking cessation across six Australian states and territories. Data were thematically analysed. Findings: Themes emerging from the data included: (a) limited time, competing priorities and shortage of health professionals; (b) a need for more knowledge and skills for health professionals; (c) influences of funding allocations and models of smoking cessation care; (d) lack of relevance of anti-tobacco messages to pregnancy and postpartum relapse; and (e) ways forward. Several barriers emerged from policies influencing access to resources and approaches to smoking cessation care for Aboriginal women. Individual-level maternal smoking cessation care provision was often under-resourced and time-constrained to adequately meet Aboriginal women's needs. Identified needs for health professionals included more time, knowledge and skills, better cultural awareness for non-Indigenous health professionals, and salient anti-tobacco messages for pregnant women related to long-term cessation. Conclusion: To drive smoking cessation in pregnant and postpartum Aboriginal women, we recommend adequately reimbursing midwives and Aboriginal Health Workers/Professionals to allow them to provide intensive support, build confidence in Quitline, continue health professionals' capacity-building and allocate consistent funding to initiatives that have been efficacious with Aboriginal women.