It must be easy for you to explain your research topic at dinner parties.

“Yes, everyone understands when you say that you’re doing research on smoking. My thesis consists of two parts. I looked at the smoke-free zone around Erasmus MC and set up a treatment for women who are or want to become pregnant and are trying to quit smoking. I did research beforehand into the moral pitfalls of rewards, what women themselves think about this and how many women drink alcohol during the first 15 weeks of pregnancy.”

What were those moral pitfalls?

“You could question whether it’s ethically responsible to reward women for quitting smoking, since that means women who have never smoked don’t get a reward. And doesn’t this affect their autonomy? Because it’s a topic that everyone understands, it’s something that everyone has an opinion about. It’s also a tricky subject. The rewards were found to be morally acceptable if they meet certain requirements.”

Why give a reward, exactly?

“Previous studies in France and England showed that rewards work. In difficult moments, a cigarette is tempting and the addicted voice in your head wonders whether that one cigarette is really that harmful. The rewards then provide some extra encouragement, since even a single cigarette means they won’t get the reward.

“People who struggle to quit smoking are often also vulnerable, because they have financial problems or a low income. The treatments that have been available thus far mainly work for a highly educated group that already has an easier time quitting smoking. It’s important that they quit too, but in the meantime the health disparities between people with a low versus high socio-economic status are only increasing.”

What was your approach in the end?

“The women could choose their own vouchers for places like Bol, Zalando or baby shops. And the amount would increase the longer they didn’t smoke. If they stopped smoking for six months, they could earn a total of €185 worth of vouchers. They also took part in group sessions and were given access to an online platform to help them quit. At the end of the treatment, 28% of the participants had quit smoking.”

What is the biggest misconception about smoking during pregnancy?

“That smoking is a choice. Cigarettes are just as addictive as heroin, but people don’t realise that because it’s seen as a normal thing. It’s extremely difficult to quit smoking, and I’ve seen so much sadness about this among the women in my study. They’re ashamed of not being able to quit, because they want the best for the health of their child. But they just can’t do it. It becomes even more difficult if you’re also dealing with stress. Thirteen per cent of the women who took part in my study didn’t have a permanent residence. Over half were unemployed, and 72% had a partner who smoked. All those factors make it harder to quit.”

What about your research on the smoke-free zone?

“Three-quarters of the adult patients were positive about the smoke-free zone. They’re already sick, so they don’t want to go through a cloud of smoke on top of that. And if they stop after they’ve just had a stressful conversation in the hospital, they’ll be tempted to smoke. We also talked to children at Sophia Children’s Hospital, and they could not understand why people would be allowed to smoke around a hospital.”

What were your main conclusions?

“One in nineteen women drinks alcohol during the first trimester of pregnancy without the healthcare provider’s knowledge. The social pressure to drink is quite high, but at the same time they know they shouldn’t do it. So when the healthcare provider asks, they say ‘no’.

“The combination of the online platform, group sessions and rewards also seems to be effective in helping women quit smoking.

“The smoke-free zone helps to discourage smoking as well, which protects vulnerable patients and children. Before the smoke-free zone was launched in September 2019, every weekday 4,000 people would stand outside and smoke. This figure has now decreased by half. And thankfully, they no longer stand at the entrance.

“Finally, confronting smokers in the smoke-free zone has proven to be very effective. Most people respond positively, put out their cigarette or leave the area.”

I read in your acknowledgements that you didn’t want to do a PhD because you thought it was stupid.

“I went to medical school to become a doctor. You have to do a mandatory 20-week research placement, and that seemed really awful to me. Such a boring office job, that’s not why I’m studying medicine, I thought. Except I really liked it. You’re curious about something and you can explore it yourself. You can make an impact. I’ve made a difference in people’s lives with this study. I get birth announcements, and sometimes people still send me baby photos.”

Was there anything about the PhD that you did think was stupid?

“There are loads of rules and it takes a lot of time to prove that you’re following them. And because of COVID-19, the study almost had to be cancelled. But these are the kinds of setbacks you have in any job. On days when I was totally exhausted, I would just go home early. I’d take a long walk with my dog and work harder again later.”

Your acknowledgements are four and a half pages. That’s really long. What does that say about you?

“I’m pretty verbose and I’m a grateful person.”

Why did you begin your thesis with the quote from life coaches Marc and Angel Chernoff: “It’s much easier to judge people than it is to understand them: understanding takes extra kindness and patience. So seek to understand before you attempt to judge. And be thankful for the rude and difficult people you meet… They serve as great reminders of how not to be.”

“I think that all of us in this society are very quick to judge and are becoming increasingly polarised. In discussions, we’re more focused on proving ourselves right than understanding others. I think life is much more fun when you take the time to listen to what someone is saying and try to understand them. Why is someone angry or sad? The same applies to smoking. If you tell patients that smoking is stupid, or that it’s child abuse, you’ll never understand why they smoke, and you’ll never help them to quit.”

Qian Huang Promotie 1022-009 – Levien Willemse

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