title: Opportunities Missed: A Cross-Sectional Survey of the Provision of Smoking Cessation Care to Pregnant Women by Australian General Practitioners and Obstetricians.
abstract: BACKGROUND
  Similar to other high-income countries, smoking rates in pregnancy can be high in specific vulnerable groups in Australia. Several clinical guidelines exist, including the 5A's (Ask, Advice, Assess, Assist, and Arrange), ABCD (Ask, Brief advice, Cessation, and Discuss), and AAR (Ask, Advice, and Refer). There is lack of data on provision of smoking cessation care (SCC) of Australian General Practitioners (GPs) and Obstetricians.
  
  
  METHODS
  A cross-sectional survey explored the provision of SCC, barriers and enablers using the Theoretical Domains Framework, and the associations between them. Two samples were invited: (1) GPs and Obstetricians from a college database (n = 5571); (2) GPs from a special interest group for Indigenous health (n = 500). Dimension reduction for the Theoretical Domains Framework was achieved with factor analysis. Logistic regression was carried out for performing all the 5A's and the AAR.
  
  
  RESULTS
  Performing all of the 5A's, ABCD, and AAR "often and always" was reported by 19.9%, 15.6%, and 49.2% respectively. "Internal influences" (such as confidence in counselling) were associated with higher performance of the 5A's (Adjusted OR 2.69 (95% CI 1.5, 4.8), p < .001), whereas "External influences" (such as workplace routine) were associated with higher performance of AAR (Adjusted OR 1.7 (95% CI 1, 2.8), p = .035).
  
  
  CONCLUSIONS
  Performance in providing SCC to pregnant women is low among Australian GPs and Obstetricians. Training clinicians should focus on improving internal influences such as confidence and optimism. The AAR may be easier to implement, and interventions at the service level should focus on ensuring easy, effective, and acceptable referral mechanisms are in place.
  
  
  CONCLUSIONS
  Improving provision of the 5A's approach should focus on the individual level, including better training for GPs and Obstetricians, designed to improve specific "internal" barriers such as confidence in counselling and optimism. The AAR may be easier to implement in view of the higher overall performance of this approach. Interventions on a more systemic level need to ensure easy, effective, and acceptable referral mechanisms are in place. More research is needed specifically on the acceptability of the Quitline for pregnant women, both Indigenous and non-Indigenous.
authors.affiliation: School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
authors.forename: Yael Bar
authors.initials: YB
authors.lastname: Zeev
authors.affiliation: School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
authors.forename: Billie
authors.initials: B
authors.lastname: Bonevski
authors.affiliation: School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
authors.forename: Laura
authors.initials: L
authors.lastname: Twyman
authors.affiliation: James Cook University, Townsville, Australia.
authors.forename: Kerrianne
authors.initials: K
authors.lastname: Watt
authors.affiliation: Centre for Behaviour Change, University College London, London, UK.
authors.forename: Lou
authors.initials: L
authors.lastname: Atkins
authors.affiliation: Hunter Medical Research Institute, Newcastle, Australia.
authors.forename: Kerrin
authors.initials: K
authors.lastname: Palazzi
authors.affiliation: Hunter Medical Research Institute, Newcastle, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Oldmeadow
authors.affiliation: School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
authors.forename: Gillian S
authors.initials: GS
authors.lastname: Gould
mesh_terms: D000328:Adult; D001315:Australia; D003376:Counseling / Q000706:statistics & numerical data; D003430:Cross-Sectional Studies; D005260:Female; D058005:General Practitioners / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D009774:Obstetrics; D010820:Physicians / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011247:Pregnancy; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012907:Smoking / Q000628:therapy*; D016540:Smoking Cessation / Q000379:methods* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D055815:Young Adult