As expected, there was significant variance in the alignment of the domains of the Aboriginal Social and Emotional Wellbeing Model and the COM-B constructs in the research evidence and health promotion materials. While some topics raised by Aboriginal and Torres Strait Islander women within the conducted studies were well covered and highly aligned with the media messages, for example, the risks from smoking, issues related to quitting (giving up vs. cutting down) and engagement with family and community, other topics were infrequently portrayed as a topic within messages. Stress was reported as a factor related to smoking in pregnancy in 36% (4/11) peer-reviewed articles we assessed and was covered by only two health promotion campaigns (11%). The limitations of health provider practices, mentioned in 45% (5/11) of the papers, featured in 22% (4/18) campaigns. Despite ‘engagement with family and community’ being an important theme in the included papers, and featuring in most campaigns, few of the health promotion resources actually targeted family and community members alongside their focus on pregnant women. Culturally meaningful messages are vitally important to resonate with Aboriginal and Torres Strait Islander peoples. Culture was represented in the majority of resources vis language and the arts, but less prominent in terms of ‘knowing the past, dreaming of the future’ (used by about 50% of campaigns) and the focus on relationships (30%) and respect for community (30%).

It is acknowledged that when developing campaigns, pragmatic choices need to be made about the focus and content of messages. Media containing too many messages may be confusing. The campaign needs to be suitable for purpose, and co-design with Aboriginal and Torres Strait Islander communities is vital to promote ownership of messages and campaigns. It may not be necessary to cover all domains of the Aboriginal Social and Emotional Wellbeing Model or all components of the COM-B Model, although a holistic approach was taken by two campaigns which covered most domains of both models (Stronger Boorais and Birthing in our Community). The Behavior Change Wheel and COM-B Model have been used as a toolkit to develop successful health promotion campaigns [25]. A behavioral diagnosis is helpful as a first stage when designing health promotional interventions. This approach has successfully been used for co-designing resources for pregnant Aboriginal and Torres Strait Islander women [56]. Appropriate intervention functions of the Behavior Change Wheel are usually chosen depending on what one aims to address in relation to the COM-B components [25]. In our review, most of the health promotion messages used education, persuasion and modelling however lesser used intervention functions that appeared in the evidence-based review, such as incentivization and enablement, could be candidates for future messages.

When using the Behavior Change Wheel and COM-B components, it is important to note that both physical and social opportunity are essential to maximize the effect of motivation and capability. Physical opportunities to quit smoking maybe lacking if health providers are not available or not skilled, and/or access to services is deficient. Social opportunities to quit smoking may be lacking if smoking is a social norm, there are few positive role models, or family and communities are not sufficiently supportive of pregnant women to quit smoking.

The themes and topics defined by this literature review and health promotion materials analyses may serve to broaden ideas for unique and less well-covered but relevant angles. Some issues raised by women within the context of research projects may be well-documented and broader due to rigorous designs to reduce bias. There are opportunities to use more of this evidence in media messages going forwards, whilst also concurrently offering these themes as considerations to communities when engaging in participatory processes of co-design.

Few research studies describe in detail the development of campaigns and how their health promotion messages were devised or the foundations for their messages. Aboriginal and Torres Strait Islander community-based workshops may be held with audience segmentation taken into account [57]. Resnicow et al. [58] recommend that culturally sensitive health promotion messages are developed on the foundation of surface and deep structure. Surface structure involves using messages that would be relevant to the outward characteristics of a target population. Deep structure takes account of the cultural, social, historical, environmental, and psychological factors that influence the target health behavior. Both surface and deep structure are important to ensure the fit and salience of messages, respectively. Deep structure aligns with many of the domains of the Aboriginal Social and Emotional Wellbeing Model related to family and kinship, community, country, spirit, spirituality, and ancestors. It also is relevant to our evidence-based themes and subthemes, especially the culturally meaningful theme.

In a survey of 47 organizations nationally about how anti-tobacco media messages were developed in Australia, Gould et al. [59] found that Aboriginal Medical Service were significantly more likely to report using deep structure in tailoring messages compared with non-government and government organizations. A dimension of “cultural understanding” evolved from a principal component analysis based on Aboriginal and Torres Strait Islander community engagement processes and the use of bottom-up approaches, community-based empowerment models and deep structure. Aboriginal organizations were more likely to excel in the use of this dimension [59].

Sinicrope et al. [60] described the protocol for the development of a social media intervention for Facebook to help Alaska Native people quit smoking based on cultural variance and surface/deep structure frameworks. The cultural variance framework considers the cultural influences on health behaviors in designing health messages including beliefs and norms, values, and Indigenous knowledge systems or ways of knowing [61]. The campaign used a co-design process based on digital storytelling with Alaska Native people who smoked and stakeholders. The phased, mixed methods approach evaluated existing media message content and co-develop test concepts for video and text-based messages and a Facebook group page. The videos, images and text are to be beta-tested through an online survey for cultural fit and impact along a range of indicators [60].

The cultural and methodological rigor embedded in our approach to the review and examination of evidence for social media campaign has not been done before for this particular population. Key components of this methodology included Aboriginal and Torres Strait Islander women as the focus of their studies who are the target audience of the included campaigns and honoring combined strengths of Aboriginal and non-Aboriginal researchers. We used strong theoretical frameworks from Aboriginal and Torres Strait Islander knowledges and behavioral and implementation science. The barriers and enablers to smoking cessation amongst pregnant Indigenous women have similarities internationally in high-income countries, although historical circumstances and social and cultural characteristics differ [62,63,64]. The methodology we developed here ensured that literature that only focused on Aboriginal and Torres Strait Islander women to ensure these women’s knowledge, attitudes and beliefs would inform the development of smoking cessation campaigns. This methodology the potential to inform the development and analysis of smoking cessation campaigns for pregnant First Nations women internationally.

There were a few limitations to the review. As a rapid review, not all the steps usually used in a systematic review were included. The search date was only until July 2019 and more recent peer-reviewed articles and campaigns may have been omitted. However, our findings will have immediate practical application in the development of an Australian Department of Health iSISTAQUIT social media campaign for pregnant Aboriginal and Torres Strait Islander women. These findings will guide the development of the community consultation and the media campaign to ensure that the topics explored are holistic according to the Aboriginal and Torres Strait Islander view of health and encompass the women’s requirements.