Lorraine Copeland. Introduction

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1 Family Practice Vol. 20, No. 4 Oxford University Press 2003, all rights reserved. Doi: /fampra/cmg410, available online at Printed in Great Britain An exploration of the problems faced by young women living in disadvantaged circumstances if they want to give up smoking: can more be done at general practice level? Lorraine Copeland Copeland L. An exploration of the problems faced by young women living in disadvantaged circumstances if they want to give up smoking: can more be done at general practice level? Family Practice 2003; 20: Objectives. The purpose of this study was to explore the barriers faced by women living in deprived circumstances if they want to give up smoking and to determine what help they would like at general practice level. Methods. The study was set in general practice in an area of socio-economic deprivation in North West Edinburgh. The practice has patients. In the first stage of the study, GPs and nursing staff at the practice were asked about their opinions of the effectiveness of wellknown smoking cessation interventions using a Likert scale format (n = 23). In the second stage, a random sample of 18 female smokers in the age group were contacted by post and asked to complete the following four measures: (i) the Hospital Anxiety and Depression Scale; (ii) a self-complete measure of knowledge of health risks for themselves and for babies and children of women smokers; (iii) opinions on effectiveness of well-known smoking cessation interventions (as completed by GPs and nursing staff); and (iv) an open-ended questionnaire, allowing qualitative responses about their smoking. Results. The findings gave insights into how the women felt about their smoking habit, their knowledge of health risks, their mental health, the needs that smoking meets for them, the difficulties faced in attempts at smoking cessation and what they think would help. Conclusions. Smoking for the women in the study group is a socially and culturally ingrained behaviour pattern with influences dating back to childhood. It is a coping mechanism many of the women displayed anxiety symptoms which they thought smoking helped with. Guilt was the overwhelming emotion associated with their habit, and this related to worries about their children s and their own health in particular. Most had tried to give up but had failed, and there was a sense of hopelessness about this relating to the difficulty involved for them. Most of the study group were highly motivated to give up, and this needs to be harnessed effectively in cessation support. Smokers and health care workers have different beliefs about what will be effective in smoking cessation. A reluctance to receive help at general practice level highlights the importance of the approach taken by GPs. Keywords. General practice, smoking cessation; socioeconomic deprivation, young women. Introduction Women, social class and smoking In Scotland, where smoking rates among women are as high as among men, and where smoking is the major cause of premature death among women, it is highlighted Received 1 August 2002; Revised 17 December 2002; Accepted 28 March Muirhouse Medical Group, 1 Muirhouse Avenue, Muirhouse, Edinburgh EH4 4PL, UK; lorrainecopeland@aol.com how smoking among those living on low income poses a double threat to well-being, not only from the risk to health but also because limited resources and poor living conditions make people more vulnerable and susceptible to the ill effects of smoking. 1 It is estimated that smoking causes deaths each year in Scotland. 2 Research has shown that increased smoking is linked to additional caring responsibilities and access to material resources. 3,4 There are clear indications too that smoking is a coping mechanism and has strong psychological roots. 5,6 It is evident that women on low income living in socially 393

2 394 Family Practice an international journal disadvantaged circumstances may be using cigarettes to bolster a problematic existence. 3 7 However, smoking, while working to promote these women s sense of wellbeing, threatens their physical health and that of their children. Smoking and the health of women and children Epidemiological research has focused on smoking behaviour as a predictor and cause of childhood and adult ill health. The crux of the issue is that smoking affects women s health plus that of their children. Women who smoke can experience problems in pregnancy, lung cancer, cancer of the cervix, coronary heart disease, fertility problems and earlier menopause. 8,9 The children of mothers who smoke can be affected in areas such as increased infant and perinatal mortality, higher incidence of low birth weight, spontaneous abortion and impaired growth, asthma and other respiratory illnesses, defective intellectual development and sudden infant death syndrome. 9,10 Forty-two percent of British children live in a household where at least one person smokes, and children under the age of 5 are admitted to hospital every year with illnesses resulting from passive smoking. 11 Another aspect of the effects of smoking is to consider whether it creates rather than relieves anxiety. There is an increasing body of evidence which contradicts the popular myth that anxious individuals are more likely to smoke. Research carried out by Johnson et al. 12 suggests that cigarette smoking may increase the risk of certain anxiety disorders during late adolescence and early adulthood, a period when most people are likely to experiment with smoking. Parrott 13 examined the findings of 30 international studies into smoking and stress to reach the conclusion that rather than helping smokers relax, it actually increases anxiety and tension. Far from acting as an aid to mood control, as many smokers believe it does, Parrott s conclusions suggest that nicotine dependency seems to increase stress and anxiety. Teenagers who experiment with smoking may increase the risk of certain anxiety disorders and, as they progress through the life cycle, may exacerbate the problem in the mistaken belief that smoking calms them down. 12,13 Socialization into smoking Children who are brought up in homes where the parents smoke have little or no choice with regard to their own exposure to smoke. Infants at home with their mother are in an especially vulnerable position. As children grow older, they imitate the behaviour they see around them. Raised in an environment where smoking is the norm, it is hardly surprising that children of smokers become smokers themselves Results from a study of primary school children s perceptions of smoking illustrate that children who have parents, siblings and friends who smoke are more likely to have tried a cigarette, more likely to want to smoke in the future and more likely to think that smoking is good rather than bad. 18 Other research draws attention to the likelihood that it is not parental influence alone which will affect children in lower social class groups taking up smoking but the fact that these children are also exposed to environmental and cultural factors which encourage them to smoke, the implication being that smoking serves a certain purpose in working class communities. 16,19 Solutions on how to quit In 2001, three-quarters (79%) of current smokers had tried to give up smoking in the past, and a half (51%) had made a serious attempt in the past 5 years. This compares with 78 and 50%, respectively, in Many smokers appear to use the most ineffective method cold turkey and few smokers report receiving help. Advice from a primary health care (PHC) team, leaflets, counselling, substitute activities and nicotine replacements have all been used, with minimal effect on the smoking habits of poor women. 5 Recommendations urge GPs to discuss smoking repeatedly and as frequently as possible The wisdom of giving unsolicited advice against smoking at nearly every consultation is questionable and may actually be counterproductive. 25,26 There is evidence that GPs themselves might not agree with this approach. Coleman et al. 27 examined why GPs do not exploit their many opportunities to discuss smoking with patients and suggest that these recommendations ignore the context in which GPs practise and that GPs would prefer a problembased approach rather than a population-based approach, i.e. to discuss smoking in the context of patient s smokingrelated problems rather than trying to influence smoking behaviour with lifestyle advice which may be unwelcome if they do not present with a smoking-related problem. These conclusions tie in with work done by Butler et al. 28 whose findings from a qualitative study of patients perceptions of doctors advice to quit smoking indicated that the approach the doctor takes in advising the smoker to quit is very important in the success of this type of intervention. Where doctors offer this advice, a patientcentred approach, i.e. one that considers how individual patients view themselves as smokers and how they are likely to react to different styles of intervention, is the most acceptable. The doctor should not use authoritative advice but should try to understand the patient as an individual. The subjects of this study were found to have already made their own evaluations about their smoking; subjects were sceptical about the power of doctors own words to influence their smoking; most believed that quitting smoking was down to the individual; subjects felt that doctors should be sensitive to the individual patient when talking about smoking. Taking into consideration the deep-rooted social, psychological and cultural aspects of smoking in working class communities, it is obviously difficult for health workers to address smoking cessation, even using the weapons of known damage to health in active and passive smoking.

3 Setting The reported research study was carried out in Muirhouse Medical Group which is a medical practice with a large patient population of patients. The area is one of economic and social disadvantage, where unemployment rates are high and relative poverty is evident in the majority of people living here. It is also an area where smoking rates are high and particularly evident among young women and teenagers. Following on from the issues explored above, this research study examined the problems facing a group of young women smokers in relation to smoking cessation. The principal aims and objectives of the study were as follows: To identify what role smoking has in the lives of the study group. To identify if these women exhibit poor psychological health. To document their awareness of health risks of smoking, both for themselves and for their dependants through passive smoking. To identify whether there is a tendency to value the short-term benefits and ignore long-term effects of smoking. To identify what type of help young women who smoke would like should they want to give up. To identify whether more can be done at general practice level. Methods The study had two stages. In the first stage, GPs and nursing staff at the practice were asked about their opinions of effectiveness of well-known smoking cessation interventions using a Likert scale format, with respondents being asked to rate these interventions in the following way: 1 = very effective; 2 = effective; 3 = uncertain; 4=not very effective; 5 = useless (n = 23) (this measure was also used with the female smokers study group). In the second stage, a random sample of 51 female patients in the age group were contacted by post. Twenty-four said they smoked and would be willing to complete a postal survey. They were then asked to complete the following four measures: (i) the Hospital Anxiety and Depression Scale (HADS); 29 (ii) a self-complete measure of knowledge of health risks for themselves and the babies and children of women smokers; (iii) a selfcomplete measure of opinions on effectiveness of wellknown smoking cessation interventions (as completed by GPs and nursing staff); and (iv) an open-ended questionnaire, allowing qualitative responses about their smoking. Eighteen replies out of a possible 24 were received (75%). Basic descriptive quantitative analysis of data gathered from measures (i), (ii) and (iii) was undertaken. Content Problems of disadvantaged young women in giving up smoking 395 and category analysis of the open-ended questionnaire was carried out and reported as themes illustrated by quotes. Responses given to measure (iii) were compared for GPs and nursing staff (referred to in the text as the PHC team) and the smokers. Results Socialization into smoking The entire group had grown up in households where it was common to have one or both parents who smoked. Seventeen (94%) also had siblings who smoked while they were growing up. The majority of the group (16, 89%) tried their first cigarette between the ages of 11 and 15 (range 8 20). The age at which they became regular smokers was slightly later, with the majority (15, 83%) saying that they became regular smokers between the ages of 12 and 16 (range 11 20). All of the group currently smoked between 20 and 40 cigarettes a day. Sixteen (89%) of the study group had children living at home. Clearly these children will be influenced by the social and cultural norms of their environment and it is likely that many too will become smokers Negative feelings Most apparent from the findings of the study were the very negative feelings that most of the group had about their smoking. Guilt was the overwhelming emotion associated with their habit, and this related to worries about their children s and their own health in particular. Many felt disgusted by the habit but powerless to give it up, as borne out by responses to the question How do you feel about your smoking? Content and category analysis was undertaken to explore responses and reported as themes drawn from the information given by the whole study group, illustrated by quotes (Table 1). These negative feelings were borne out by the fact that most of the group had made several failed attempts to quit. Smoking is a coping mechanism As indicated by other research, smoking has a multifaceted role in the daily lives of the study group, the pivotal role being that of a coping mechanism. 3 7 The findings of this study clearly agree. Sixteen (89%) respondents mentioned that they thought smoking helped them cope when they were feeling stressed or had a particular problem, e.g. money problems, divorce, bereavement, worries about children. The HADS scale was used to detect the current state of mind of the study group. [Each item is scored from 0 to 3 and so the total scores range from 0 to 21 for the anxiety subscale and also for the depression subscale. The four score ranges can be classified normal (0 7), mild (8 10), moderate (11 14) and severe (15 21).] Although the nature of anxiety items on the HADS scale may result in several of these being endorsed by the general adult population, many of this

4 396 Family Practice an international journal TABLE 1 How the study group felt about their smoking Themes Illustrative quotes Feelings of concern relating to children Feelings of concern about health I do feel guilty smoking in front of my children I don t enjoy smoking it is a habit I wish I didn t smoke. I am totally aware of what it can do to your body. (My granddad died of lung cancer) and I do feel guilty and angry with myself for starting in the first place Feelings of distaste I hate the smell. I feel guilty. I don t like my life revolving around cigarettes Feeling that smoking has become a Smoking has just become a habit something I ve done for a long time I can t give it up... hopeless, innate behaviour pattern group did display levels of anxiety that differed from what might be termed generally acceptable. The mean anxiety score for the group was 8.5, which is higher than found in other studies providing normative data for the general adult population (6.14 by Crawford et al. 30 and range for three samples by Spinhoven et al. 31 ). The mean depression score for the group was 4.8, again higher than that of Crawford et al. 30 (3.68) and Spinhoven et al. 31 (range for three samples). Figure 1 illustrates the distribution of these scores in the group. While there were very few of the group who had depression scores out of the normal range, several appeared to be anxious individuals and displayed anxiety scores out of the normal range when measured on the HADS scale (Fig. 1). Whether this was the situation prior to acquiring the smoking habit in their early teens will never be known but, conversely, the possibility that the chemicals contained in cigarettes have actually increased their anxiety levels cannot be ruled out. 12,13 As well as a psychological coping mechanism, smoking is associated in the minds of the study group with sustenance, and many will smoke as part of taking food and/ or drink. A typical quote illustrating this association is: I get up in the morning and need a coffee and a cigarette and after each meal and one last thing at night. Only 5 a day would get me through. The rest are because they re just there and they get me through the day. (20-a-day smoker) Knowledge of health risks Regarding knowledge of health risks caused by smoking, this study s findings were similar to the Smoking Related Behaviour and Attitudes Survey (2001) 20 where, for example, 90% of respondents said that passive smoking increased the risk of chest infections in children (compared with 72% in the current study), 54% said that passive smoking increased the risk of cot death (compared with 62% in the current study) and 28% said that passive smoking increased the risk of ear infections in children (compared with 22% in the current study). The level of knowledge fell concerning risks to babies, and knowledge of the less obvious effects of maternal smoking such as sore ears (glue ear) and lower intelligence in children was poor (Fig. 2A). A similar pattern emerged with knowledge of risks to the women themselves, with a high level of awareness of risks displayed for the better-known illnesses such as lung cancer, respiratory problems and heart disease. Knowledge of menstrual and fertility problems caused by smoking was poor (Fig. 2B). The role that knowledge of health risks plays is explored in the Discussion. Difficulties faced in quitting The whole group wanted to give up, and 17 (94%) had actually tried, many having made several attempts. Most had used forms of support [nicotine replacement therapy (NRT), Helplines, acupuncture, GP, books]; the rest tried willpower alone. All had failed. The reasons for failure were: Lack of will power A trigger event such as starting a new job, marital problems or bereavement Nothing to help cope with daily life Weight gain Missing the pleasure of social smoking Contact with other smokers FIGURE 1 Distribution of anxiety and depression scores among the study group Who would female smokers approach for help? In trying to get the help they want in order to give up, smokers were asked the following question focusing on

5 Problems of disadvantaged young women in giving up smoking 397 The study group s knowledge of health risks to (A) babies and children of women smokers and (B) to themselves FIGURE 2 who they would be likely to approach: Who would you approach if you wanted advice about giving up smoking (GP, health visitor, pharmacist, family member or friend, no one)? A very mixed response to this question was given, with only five actually saying that they would approach their GP, as illustrated in Figure 3. The group were then asked the following question: Would you find it difficult to approach your GP to discuss smoking issues? Again, content and category analysis was undertaken to explore responses and reported as themes drawn from the information given by the whole group (including those who said they would FIGURE 3 Study group s responses to the question Who would you approach if you wanted advice about giving up smoking? approach their GP in the previous question). The main themes, illustrated by quotes, indicated that many of the group would feel uncomfortable raising the subject of smoking with their GP (Table 2). What did the female smokers think would be helpful? (i) NRT many of the study group expressed the wish to try nicotine replacement therapy, although those who had already tried this did not find it helpful in quitting. (ii) Alternative therapies many of the group mentioned a willingness to try hypnosis, or acupuncture. (iii) Social support some smokers felt that they would be able to stop with support from family and friends. (iv) Others said that they would be willing to try anything at all. The data from opinions on effectiveness of well-known smoking cessation interventions were then compared for the female smokers study group and the PHC team. Variation between the two study groups was clearly evident in the opinions of interventions that would not be effective. For the purposes of illustrating the data, intervention ratings of 4 (not very effective) and 5 (useless) were combined to give the term not effective, and this is illustrated in Figure 4 as percentages. The smokers, in general, gave higher ineffectiveness ratings to all interventions. The main difference which emerged was that smokers did not value an advice-only approach taken by health care workers, with 94% saying that it would not be effective coming from a GP and 94%

6 398 Family Practice an international journal TABLE 2 Why smokers would not approach their GP Themes Illustrative quotes GPs are too busy Smokers are to blame for their own health problems Fear of facing reality I feel like the GP is too busy. On a visit to my doctor I approached my GP about this but he wasn t very helpful Doctors are there for people with genuine health problems. This is my problem and understandably there is little sympathy for smokers He would tell me about cancer, which I know already. Most of my family have died of cancer saying that it would not be effective coming from other members of the health care team, again highlighting the need for a sensitive patient-centred approach if raising the issue of smoking with women like those in the study group (Fig. 4). It was evident, however, that both the PHC team and the female smokers felt that NRT would be beneficial, particularly if used in conjunction with support from a health care worker trained in smoking cessation support. Discussion FIGURE 4 Smoking for the women in the study group was a socially and culturally ingrained behaviour pattern with influences dating back to childhood. It was associated in the minds of the study group with sustenance, and many will A comparison of opinions of effectiveness of smoking cessation interventions smoke as part of taking food and/or drink. They also thought that smoking would calm them down if they were worried or anxious, and many of the group did appear to be anxious individuals. However, as most of the group acquired the smoking habit in their early teens, there was no way of knowing whether smoking did help their anxiety or might actually have increased it. 12,13 Guilt was the overwhelming emotion associated with their habit, and this related to worries about their children s and their own health in particular. Many felt disgusted by the habit but powerless to give it up, as borne out by comments made and the fact that most of the group had made several attempts to quit. It was clearly evident that the positive gains from smoking were of limited value to the group and that they did not outweigh the negatives. The level of knowledge displayed by the study group regarding the better-known health risks of smoking was

7 Problems of disadvantaged young women in giving up smoking 399 similar to the findings from the Smoking Related Behaviour and Attitudes Survey (2001). 20 A lack of knowledge was displayed about the less obvious health risks to children, and knowledge of menstrual and fertility problems caused by smoking was poor. Whether there is any value in publicizing these risks is debatable, as a major effect might be to increase the feelings of guilt that these women have without offering them a more tenable solution on how to kick the habit. From the perspective that the study group were prepared to take the risks to their health and the health of those who live with them, it could be argued that they valued the short-term benefits of smoking as opposed to the distant problems it might give them. However, the problem is to a greater degree more complex and is tied in with many issues, not least the difficulty in fighting nicotine addiction in an environment where smoking is highly prevalent and is an immediate and freely available coping mechanism. 3 7 It may not be enough to succeed with combating nicotine addiction when there is not a viable substitute to fill the role that smoking, with all its psychological and cultural associations, plays so fully for many women similar to those in this study group. However, there was a clear indication that the motivation to quit is present, in that all except one of the group had tried to stop, some making several attempts, and it is this motivation which clearly needs to be harnessed and supported in the right way by health care workers. Health promotion faces a difficult challenge because GPs are being encouraged to give smoking cessation support to patients. How it is presented to the patient is clearly of vital importance to this being a successful cessation intervention, and taking too directive an approach might not be welcomed. A reluctance to approach GPs for help with smoking cessation was evident, in that unsolicited advice from the PHC team in general did not appear to be valued by these smokers. This study is limited in its generalizability because numbers were small and selected from one general practice. However, there is no reason to suppose that the women in the study group differed in any respect from other female smokers in this age group currently registered with the practice. In terms of the characteristics of deprived populations, this general practice catchment population is fairly typical. The following quote from Jarvis and Wardle 32 depicts the sample population with accuracy The factors that predict smoking include material circumstances, cultural deprivation, and household circumstances. This illustrates what might be proposed as a general law of Western industrialized society; namely, that any marker of disadvantage that can be envisaged and measured, whether personal, material, or cultural, is likely to have an independent association with cigarette smoking. It is essential that health workers in this type of environment have access to information that will help them maximize their influence in the problematic area of deprivation and health. Services that are particularly designed for deprived populations, which take into account their special requirements, are more likely to have an impact. It is clearly indicated from this small study that more in-depth research (probably qualitative) is required to determine the most effective smoking cessation interventions for those living in economically and socially deprived circumstances, and it is likely that there will be gender differences in the type of health care input required. (Preliminary findings from a current study of the factors that will influence success in using nicotine patches in a deprived population have found that employed females were more likely to have high nicotine dependency and, conversely, this was true for unemployed males). 33 Those involved in the primary health care arena are arguably more likely than those in secondary care to have an influence on changing behaviour that is detrimental to patients health. This stems from their more frequent contact with, and personal knowledge of, the patients in their care. However, it may be that certain misconceptions are held by health care workers about the type of help their patients want from them. For example, indications from this study were that the PHC team thought their advice would be effective in helping smokers to stop, but the smokers disagreed (see Fig. 4). Further research of a qualitative nature regarding what help smokers actually want from their GP would be useful to policy makers and those working in the primary health care arena. In conclusion, although this study was on a fairly small scale (23 health care workers and 18 female smokers), attempts were made to cover issues in some depth in an effort to provide useful insights from both the PHC team and female smokers that might highlight further areas requiring research. More effective health care provision is only likely to emerge when those working in problematic areas are best informed about what their clients want and need from the health care service. References 1 Crossan E, Amos A. Under a Cloud. Women, Low Income and Smoking. Health Education Board for Scotland and Chief Scientist Office; ASH Scotland (2002) Accessed on 10 July Graham H. Women s smoking and family health. Soc Sci Med 1987; 1: Graham H. 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