The pregnant smoker: a preliminary investigation of the social and psychological influences

Transcription

1 Journal of Public Health Medicine Vol. 9, No., pp Printed in Great Britain The pregnant smoker: a preliminary investigation of the social and psychological influences C. Haslam, E. S. Draper and E. Goyder Abstract Background Smoking during pregnancy is an important challenge to public health. An understanding of the psychological and sociological bases of maternal smoking is essential to the development of effective smoking cessation interventions. The aim of this study was to explore the psychosocial factors that underpin maternal smoking. Methods Semi-structured interviews were conducted with 00 antenatal attenders at Leicester Royal Infirmary, NHS Trust, UK. Results Twenty-nine per cent were smokers, per cent ex-smokers and 49 per cent were never smokers. Around half of the ex-smokers (49 per cent) had reportedly given up smoking during their current pregnancy. Around a third (9.5 per cent) of the ex-smokers had experienced previous problems associated with maternal smoking, including spontaneous abortion, cot death and premature birth. Of the current smokers, 69 per cent claimed that they would like to give up smoking; indeed, 59 per cent had tried to stop smoking. Emotional factors were important in maintaining smoking for two-thirds of the smokers. Significantly more of the smokers (75 per cent) had partners who smoked compared with the never-smoking women (0 per cent; p < 0.00). There was no difference in the level of knowledge about the dangers of maternal smoking between smokers, ex-smokers and never smokers. Conclusions Pregnant smokers are as aware of the health risks'as non-smokers. Effective intervention strategies need to focus not only on the pregnant woman's smoking status but also offer help to partners, close family members and friends. Interventions need to address the social and psychological factors that maintain maternal smoking. Keywords: smoking, pregnant women, interviews Introduction The health risks associated with cigarette smoking during pregnancy are now well established. ' Infants of smokers are grams lighter than those of non-smokers. ' 4 The low birthweight associated with maternal smoking increases the risk of perinatal mortality and morbidity, especially in those women who are already at high risk on biological or social grounds. 5 " 9 The proportion of low-birthweight babies resulting from such women is exacerbated by maternal smoking. 0 The risks to the mother's own health are also considerable. Estimates of mortality related to tobacco use are rising sharply. One estimate puts the figure at deaths in the United Kingdom each year.' l Reducing the prevalence of smoking among pregnant women should therefore offer significant benefits to the health of both mothers and infants. The Government White Paper The health of the nation calls for at least per cent of women to stop smoking at the start of their pregnancies by the year 000. Indications of current trends in smoking behaviour among pregnant women are vital for both target setting and monitoring. Draper et a/. examined the smoking habits of pregnant women in Leicestershire, UK, from 977 to 989. Over the years examined, some 8 per cent of women smoked throughout their entire pregnancy. A greater proportion of younger, more socially disadvantaged pregnant women smoked compared with older, more socially advantaged pregnant women. Similarly, Madeley et al. 4 found that 7 per cent of pregnant women in Nottingham, UK, smoked and only one in four was successful at stopping at some point during pregnancy. No change in smoking habit was reported by a quarter of the mothers, and these authors suggest that this proportion may represent the 'irreducible minimum'. To reduce maternal smoking it is important to understand the factors which maintain smoking during pregnancy and which affect smoking cessation. Although the physical dependence on tobacco can be potentially as strong as the physical dependence to heroin, there are also powerful social and psychological factors which maintain an individual's smoking habit and hinder attempts to stop smoking. Smokers report that the Department of Human Sciences, Loughborough University, Loughborough, Leicestershire LEI TU. C. Haslam, Lecturer in Psychology Department of Epidemiology and Public Health, Leicester University, -8 Princess Road West, Leicester LEI 6TP. E. S. Draper, Research Fellow in Perinatal Epidemiology E. Goyder, Medical Research Council Training Fellow in Health Services Research Address correspondence to Dr C. Haslam. Oxford University Press 997 Downloaded from by guest on November 08

2 88 JOURNAL OF PUBLIC HEALTH MEDICINE difficulty in not smoking is usually unrelated to the physical withdrawal symptoms; relapse is often associated with particular situations where the behaviour has been enacted in the past or with situations involving stress. 6 Hilton and Condon 7 used a self-completion questionnaire to explore the factors that affect smoking during pregnancy among 40 Australian women. Twenty-nine per cent of the smokers stopped whereas 7 per cent continued to smoke. Concern about harm to the baby was the main influence on smoking behaviour. Gillies et a/. 8 used a self-completion questionnaire to examine the reasons for smoking among a sample of 490 pregnant women in Nottingham, UK. Mood control was the most popular reason (to relax, calm down, enjoyment, out of boredom). Pregnant women were more likely to smoke as a result of boredom if they were single, especially if divorced or separated, from unskilled or semi-skilled occupational groups, or if they had a partner who was unemployed. Gillies et al. argued that more qualitative investigation is required to gain further insights into why pregnant women smoke and that such information is essential to the development of effective intervention strategies. This study employed a semi-structured interview with antenatal attenders; the aims of this preliminary study were to:. document the social and psychological factors which maintain smoking and which affect smoking cessation during pregnancy;. assess the level of knowledge of pregnant women regarding the dangers of maternal smoking;. determine what advice smokers had been given to help them stop smoking during their pregnancy; 4. establish what support women feel they need to help them stop smoking during their pregnancy. Method A semi-structured interview schedule was developed which comprised a series of closed and open questions. The interview schedule assessed sociodemographic variables followed by questions about current and previous smoking behaviour and the factors which have caused relapse after smoking cessation. Knowledge of health risks associated with maternal smoking and exposure to health promotion advice were assessed using open-ended questions. Responses to the questions were recorded on the schedule by the researcher. The schedule was piloted on 0 antenatal attenders at the Leicester Royal Infirmary, NHS Trust, and was then further developed and refined in the light of the pilot study. Copies of the schedule can be obtained from the first author. The target sample for the survey was 00 women attending the antenatal clinics at the Leicester Royal Infirmary, NHS Trust It was not a random sample; however, the researcher selected clinic dates to cover all consultants. On these dates, all women attending the clinic were approached and asked to participate in the study. In the antenatal clinic a private room was made available for the interviews. Based on the women's responses to questions about occupation, women and their partners were ascribed to social class groups (Office of Population Censuses and Surveys 9 ). A smoker was defined as someone who smokes at least one cigarette per day. The data were analysed using the SAS package. 0 Given the non-parametric nature of the data, Wilcoxon tests were conducted to examine differences between smokers, ex-smokers and never smokers. Results The data comprised 00 completed semi-structured interviews which were conducted with antenatal attenders at Leicester Royal Infirmary, NHS Trust. Four women refused to participate in the study and nine interviews had to be discarded because they were incomplete. The complete response rate was therefore 9.5 per cent. The age range of the sample was 5-4 years, with stages of pregnancy between 6 and 4 weeks. The distribution of the sample by trimester was.5 per cent in the first trimester, 5 per cent in the second trimester and 5.5 per cent in the third trimester. There were 58 (9 per cent) smokers, 44 ( per cent) ex-smokers and 98 (49 per cent) non-smokers. The mean number of cigarettes smoked was 4 per day. Of the current smokers, 69 per cent claimed that they would like to give up smoking. When asked 'Have you tried to stop smoking during this pregnancy?' 59 per cent stated that they had tried to give up smoking. When asked what caused them to relapse, these smokers cited mood changes (40 per cent), social pressure (0 per cent), craving or habit (7 per cent), boredom ( per cent), stress (9 per cent) and because feelings of nausea had ceased ( per cent). Around half of the ex-smokers (49 per cent) had reportedly given up smoking during their current pregnancy. Around a third (9.5 per cent) of the ex-smokers had experienced previous problems associated with smoking during pregnancy, including spontaneous abortion, cot death and premature birth. The comparable figures for current smokers and never smokers who had experienced such problems were 9. per cent and 6.5 per cent, respectively. Differences between smokers and never smokers Forty per cent of smokers were married compared with 78 per cent of the never smokers (x, p < 0.000). In terms of more general 'social support', 8 per cent of current smokers were married or cohabiting compared with 9 per cent of the never smokers (x, p < 0.05). Never smokers were more likely to be of higher social class (I and IT). Smokers were more likely to be in social classes IV, V or unemployed. The same trend was observed for partner's social class (Wilcoxon, p < 0.005). Smokers tended to have left school or full-time education earlier than never smokers (Wilcoxon, p < 0.000). Seventyfive per cent of current smokers had partners who smoked (this Downloaded from by guest on November 08

3 THE PREGNANT SMOKER 89 Table The smoking habitsof family or friends of current, ex-smokers and never smokers (95 pier cent CIs given in parentheses) Current smokers Ex-smokers Never smokers None smoke Some smoke Most smoke All smoke 0 5 (0-) 5 (-48) 4 (0-56) 9(0-) 5 4 (4-5) 5 (7-67) 7(5-4) 9 (-) 6 4(5-) 6 (54-74) (6-9) (0-9) statistic is derived from the finding that, of the 55 pregnant smokers who had a partner, 4 of these had a partner that smoked). The comparable figure for never smokers was 0 per cent (x, p < 0.000). Table outlines the smoking habits of family members and friends. Pregnant smokers had higher proportions of family members and friends who were smokers, compared with pregnant women who had never smoked (Wilcoxon, p < 0.000). Differences between smokers and ex-smokers Whereas 40 per cent of current smokers were married, 64 per cent of ex-smokers were married (x, p < 0.05). In terms of 'social support' there was no significant difference between the two (8 per cent of current smokers and 84 per cent of ex-smokers were married or cohabiting). No significant differences were observed between the social class of smokers and ex-smokers. Also, no significant differences were found for partner's social class. Smokers tended to have left school or full-time education earlier than ex-smokers (Wilcoxon, p < 0.005). Seventy-five per cent of current smokers had partners who smoked compared with 40 per cent of the exsmokers (x, p < 0.00). Table outlines the smoking habits of family and friends. Pregnant smokers had higher proportions of family and friends who were smokers, compared with pregnant ex-smokers (Wilcoxon, p < 0.05). Open-ended interview questions When asked 'what, in particular, causes you to have an urge to smoke?', two-thirds of the current smokers gave an emotional state (stress, boredom, feeling upset) for their answer. When asked about the effects of maternal smoking on the health of the child, 50 per cent of women in all groups cited (with no prompting) two or more possible health risks, including low birthweight or prematurity, breathing problems, congenital malformations, low IQ and circulatory problems. Wilcoxon tests indicated no significant difference in number of health risks cited by smokers, ex-smokers and never smokers. Twothirds of current smokers felt these potential dangers were not personally relevant because they had cut down, or they believed it was too late, or as a result of personal experience of uncomplicated births following maternal smoking. Seventy-four per cent of the current smokers had received advice about giving up smoking during their current pregnancy. The sources of advice were a general practitioner (GP) (4 per cent), midwife (9 per cent), obstetrician ( per cent), or family and friends (9 per cent). It is notable that 6 per cent of the current smokers claimed to have received no advice on stopping smoking during their pregnancy. This finding did not appear to be a function of lack of contact with health care professionals, as 5.4 per cent of the current smokers were in their third trimester, 4. per cent were in their second trimester and.4 per cent were in their first trimester. Moreover, of those smokers in their first trimester, only three out of the women indicated that they had not received advice regarding smoking during pregnancy. All the current smokers were asked what would help them to give up. Table shows the responses. Ex-smokers cited the same sources of advice as current smokers, and stated that their reasons for giving up smoking included pregnancy (5 per cent), nausea during pregnancy ( per cent), their own health (6 per cent), financial considerations ( per cent), being unable to smoke at work (4 per cent) and pressure from partner (4 per cent). This suggests that among these ex-smokers, pregnancy and nausea associated with pregnancy were powerful motivators for smoking cessation. Table Factors that pregnant smokers believed would help them to stop smoking during pregnancy What would help women to give up? Nothing Partner, family or friends giving up Self-motivation More information on how to stop Social pressure Knowing that own baby was at risk Nicotine substitute* Something to occupy me Less stress Hypnotherapy Loss of craving Financial incentive * Contra-indicated in pregnancy- n 7 4 % CJl Downloaded from by guest on November 08

4 90 JOURNAL OF PUBLIC HEALTH MEDICINE Discussion The sample comprised 9 per cent smokers, per cent exsmokers and 49 per cent non-smokers. Around half of the ex-smokers (49 per cent) had reportedly given up smoking during their current pregnancy. Of the current smokers, 69 per cent claimed that they would like to give up smoking; indeed, 59 per cent had tried, unsuccessfully, to stop smoking. These results are in line with the results of Condon and Hilton, who found that among pregnant women in Australia, 40 per cent reported that they had 'tried and failed' to cut down or stop smoking. The present study indicated that pregnant smokers were more likely to have had less education, be unmarried and of lower socio-economic status, compared with never smokers. Pregnant smokers had less education than ex-smokers but there were no significant differences in social class. This concurs with previous work demonstrating that women who give up smoking during pregnancy tend to have more years of education than those who fail to stop smoking. ' The finding that pregnant smokers were significantly more likely to have partners, family or friends who smoke is in line with other studies in the United States, 4 Australia and the United Kingdom. 6 This strongly suggests that intervention strategies should not only be aimed at the pregnant woman, but should also make available help and advice on stopping smoking to partners and close family members and friends. Such an approach will offer important support to the woman in her attempts at giving up, and is particularly pertinent given the effects of passive smoking on the developing child. 7 There is evidence that pregnant women who give up smoking tend to have stronger beliefs in the harmful effects of maternal smoking. 4 " 5 Wakefield et at. 6 conducted a survey of working class women in Nottingham and Coventry, UK, comparing the characteristics of women who quit smoking during pregnancy and were still ex-smokers at the six month post-natal stage with 47 women who had continued to smoke throughout and after pregnancy. Three variables were associated with cessation: having previously quit for more than a week, having a non-smoking partner, and believing the children of smokers were more likely to contract infections. Health beliefs were elicited by asking women to respond 'yes', 'no' or 'can't say' to statements about whether children who live with people who smoke are more likely to contract conditions such as 'chesty cough', 'wheezing' or 'increased risk of infections'. Only beliefs about 'increased risk of infections' showed a significant difference between smokers and quitters. The present study used open-ended questions to ask pregnant women about the health risks associated with maternal smoking. It was found that smoking during pregnancy was not distinguished by ignorance of the risks, as two-thirds of all women (smokers, ex-smokers and never smokers) were aware of at least two potential dangers of maternal smoking. So knowledge of risk does not appear to be a major determinant on maternal smoking. However, being able to cite some health risks associated with maternal smoking does not mean that the individual is necessarily convinced that these risks represent a real threat to the health of their unborn child. In the next phase of this research, in-depth interviews are being conducted with antenatal attenders who smoke to explore their assessment of risk and the rationalizations they may have developed about their smoking behaviour. Health education seems to have been effective in educating women about the potential dangers of maternal smoking but has failed in terms of translating this knowledge into behaviour change for the 'irreducible minimum' of women (Madeley et al. 4 ). Women are aware of the health risks but this is not necessarily reflected in their behaviour. Previous uncomplicated pregnancies experienced by themselves, their relatives and peers may mean that some women cope with the cognitive dissonance generated by smoking during pregnancy by believing they have some 'personal immunity' against the health risks. Cessation strategies should identify and confront any inaccurate perceptions of risk by both the pregnant women and their partners. Pregnancy offers an important opportunity for raising awareness about the health hazards associated with smoking. Some 6 per cent of the current smokers in this study claimed to have had no advice on stopping smoking during their pregnancy. There is considerable scope for improving antenatal smoking cessation initiatives. Our research indicates that emotional factors are important in the maintenance of maternal smoking, which suggests that interventions should offer support as well as information. Reading 8 suggested that anxiety and stress may make it less likely that a woman will comply with health care recommendations, and will lead to reduced uptake of antenatal care. Therefore, effective smoking cessation strategies should not burden pregnant women with excessive guilt about their smoking and add to their anxiety. In their review of the area, Lumley and Astbury noted that current anti-smoking messages aimed at pregnant women are too strident in their tone, and ignore the psychological and physical aspects of the addiction, the meaning of the behaviour for the women involved, and the guilt and anxiety felt by smokers. The present authors suggest that a more positive approach to reducing maternal smoking may be to offer support (such as skills training and relaxation training) to help women cope with daily stresses rather than using cigarettes to help alleviate stress. This study has a number of limitations. The respondents were not selected randomly, therefore the estimates of percentage of smokers, ex-smokers and never smokers cannot be representative of pregnant women in the UK population. However, the aim of this study was not to examine the prevalence of smoking among pregnant women but rather to explore some of the social and psychological factors which underpin maternal smoking. The semi-structured interviews employed in this investigation (as opposed to the usual selfcompletion questionnaires) allowed open-ended questions and gave the opportunity to check the responses and assess women's views in greater depth. Downloaded from by guest on November 08

5 THE PREGNANT SMOKER 9 The next stage of this research will involve more in-depth qualitative research leading to the development of an antenatal smoking cessation package aimed at young socially disadvantaged pregnant women (those most resistant to current smoking cessation techniques). This in-depth research will comprise interviews and focus groups with young (less than 5 years of age), or socially disadvantaged (unemployed or social classes IV and V) pregnant smokers, their partners and close family members. The intervention will be based on the 'Quit for Life' Programme. 9 This programme will be adapted taking into consideration data from the in-depth interviews and focus groups. The package will be evaluated using randomized controlled trials in community and hospital settings. Smoking among pregnant women is a major public health issue and represents an important challenge to perinatal health. Research into the psychological and sociological bases of smoking during pregnancy promises a more complete understanding of the mechanisms which maintain maternal smoking and which curtail attempts to stop. Such an understanding will have important practical implications for behavioural treatments aimed at helping pregnant women to stop smoking, and will offer potential health benefits for women and their infants. Acknowledgements We would like to thank Professor D. Taylor, Head of the Department of Obstetrics and Gynaecology, Leicester University, consultants and the antenatal clinic staff at the Leicester Royal Infirmary, NHS Trust, UK. References Abel EL. Smoking and pregnancy. J Psychoactive Drugs 984; 6: 7-8. Lumley J, Astbury J. Advice for pregnancy. In: Chalmers I, Enkin MW, Keirse MJNC, eds. Effective care in pregnancy and childbirth, Vol.. London: Open University Press, 989. Lowe CR. Effects of mothers' smoking habits on birth weight of their children. Br Med J 959; : Brooke OG, Anderson HR, Bland JM, Peacock JL, Stewart CM. Effects on birth weight of smoking, alcohol, caffeine, socioeconomic factors and psychosocial stress. Br Med J 989; 98: Meyer MB, Jonas BS, Tonascia, JA. Perinatal events associated with maternal smoking during pregnancy. Am J Epidemiol 976; 0: Meyer MB, Tonascia JA. Maternal smoking, pregnancy complications and perinatal mortality. Am J Obstet Gynecol 977; 8: Cnattingius S, Haglund B, Meirik O. Cigarette smoking as a risk factor for late fetal and early neonatal death. Br Med J 988; 97: Kleinman JC, Pierre, MB, Madans JH, Land GH, Schramm WF. The effects of maternal smoking on fetal and infant mortality. Am J Epidemiol 988; 7: Malloy MH, Kleinman JC, Land GH, Schramm WF. The association of maternal smoking with age and cause of infant death. Am J Epidemiol 988; 8: Rush D, Cassano P. Relationship of cigarette smoking and social class to birthweight and perinatal mortality among births in Britain, 5- April 970. J Epidemiol Commun Hlth 98; 7: Peto R, Lopez AD, Boreham J, Thun M, Heath Jr, C. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 99; 9: Department of Health The health of the nation. A strategy for health in England. London: HMSO, 99. Draper ES, Kurinczuk JJ, Clarke M. Smoking during pregnancy: one approach to target setting (in preparation). 4 Madeley RJ, Gillies PA, Power L, Symonds EM. Nottingham Motfiers Stop Smoking Project - baseline survey of smoking in pregnancy. Community Med 989; : US Department of Health and Human Services. Nicotine addiction: a report of the Surgeon General. Washington. DC: USDHHS, West R. Psychological theories of addiction. In: Glass IB, ed. The international handbook of addiction behaviour. London: Routledge, Hilton CA, Condon JT. Changes in smoking and drinking during pregnancy. Aust NZ J Obstet Gynaecol 989; 9: Gillies PA, Madeley RJ, Power FL. Why do pregnant women smoke? Public Hlth 989; 0: Office of Population Censuses and Surveys. Standard occupational classification, Vol.. London: HMSO, SAS Institute. SAS user's guide: basics, Version 5. Cary, NC: Statistical Analysis Systems Institute, Inc., 985. Condon JT, Hilton CA. A comparison of smoking and drinking behaviours in pregnant women: who abstains and why? Med J Aust 988; 48: Campo P, Faden RR, Brown H, Gielen AC. The impact of pregnancy on women's prenatal and postpartum smoking behaviour. Am J Prev Med 99; 8: 8-. Cnattingius S, Lindmark G, Meirik O. Who continues to smoke while pregnant? J Epidemiol Commun Hlth 99; 46: Quinn VP, Dolan Mullen P, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and Downloaded from by guest on November 08

6 9 JOURNAL OF PUBLIC HEALTH MEDICINE predictions of relapse before delivery. Addictive Behav 99; 6: Wakefield MA, Jones WR. Cognitive and social influences on smoking behaviour during pregnancy. Aust NZJ Obstet Gynaecol 99; : Wakefield M, Gillies P, Graham H, Madeley R, Symonds M. Characteristics associated with smoking cessation during pregnancy among working class women. Addiction 99; 88: Ehrlich R, Kattan M, Godbold J. Childhood asthma and passive smoking: urinary cotinine as a biomarker of exposure. Am Rev Respir Dis 99; 45: Reading EA. The influence of maternal anxiety on the course and outcome of pregnancy: a review. Health Psychol 98; : Marks DF. The Quit for Life programme. An easier way to stop smoking and not start again. Leicester: British Psychological Society, 99. Accepted on 4 December 996 Downloaded from by guest on November 08