1 Children born to mothers who have smoked sellectchem during pregnancy are more susceptible to respiratory infections and asthma,2 and more likely to experience learning and cognitive development disorders.3 These and the increased risks

of other chronic diseases throughout childhood4 mean that women who are pregnant and smoking are strongly advised to quit. However, many continue to smoke during and beyond pregnancy, putting themselves and their children at risk.5 6 Women who smoke while pregnant often have fewer qualifications, come from poorer communities where smoking is more prevalent,7–9 and experience a reduced urgency to quit.4 10 11 Because smoking is entrenched in some communities, women often see other women smoking while pregnant, and may themselves have been born to smokers.12 The reported harms of smoking during pregnancy may diverge from their own experiences and the absence of overt or perceived harm may imply that continued smoking does not inevitably harm unborn children.12–14 Women who smoke while pregnant (or who smoke following the birth of their child) may also see quitting as segregating them from social networks at the very

time they would like greater support,6 15 and report that smoking fosters social interactions, provides respite from monotonous jobs and represents opportunities to relax.5 11 16–20 Promoting the health risks of smoking during pregnancy may thus fail to trigger quit attempts because the distal risks smokers perceive as uncertain fail to outweigh the proximal benefits they receive.8 21 Cessation messages must decrease the value placed on smoking as a reward, offer alternatives, challenge the myths and self-exempting beliefs pregnant

smokers construct, and provide stimuli that prompt and support quit attempts.9 22 They must balance the risk that dissonance inducing messages promote reactance and counter-argument rather than action, and leave behaviour more ingrained.23 Dissonance and reactance Conflicting beliefs and behaviours create tension that may promote behaviour GSK-3 change as individuals try to align their thoughts, feelings and actions to reduce discord.24 Smokers may experience dissonance in social settings, where smoking has become increasingly unacceptable, and when reflecting on the harm smoking causes to themselves or others.25 The resulting unease may provide a powerful stimulus that potential cessation messages could utilise. However, while cognitive dissonance should logically foster quit attempts, behaviour change is not always straightforward, even when dissonance is high and uncomfortable. For example, addicted smokers may struggle to quit, despite wishing to become smoke-free.13 26 Tensions caused by discrepancies between smokers’ beliefs, a desire to quit and continued smoking may become acute among women who are pregnant and smoking.