Healthier women, healthier children: Addressing pregnancy and smoking requires women-centred approach

CrossCurrents

By Avril Roberts

 

Maternal smoking during pregnancy remains a serious public health problem, wreaking havoc on the health of women, fetuses and newborns. Yet smoking cessation interventions for pregnant and postpartum women are not only scarce but often ineffective.

Many women quit smoking or reduce tobacco use, usually in the first few weeks of pregnancy. However, approximately 25 per cent will relapse before delivery, 50 per cent within four months postpartum, and by the time the baby is one year old, between 70 and 90 per cent are smoking again, according to Expecting to Quit, a 2003 review of smoking cessation interventions for pregnant and postpartum girls and women published by the British Columbia Centre of Excellence for Women’s Health (BCCEWH) in Vancouver. "Some women go through a temporary abstinence on their own or with some intervention from their physician or others, but from a woman’s health point of view, they’re no further ahead at the end of their postpartum year," says Lorraine Greaves, executive director of the BCCEWH and lead on the review.

Greaves finds fault with traditional fetus-centric approaches to smoking cessation. "Once the baby is born, that external motivation to quit is removed," she says. "Success during pregnancy or postpartum means focusing on women’s health as the motivation for smoking cessation or reduction,” says Greaves. “This doesn’t mean ignoring the importance of fetal health, but without healthy women there are no healthy children. We need to send the message that quitting smoking is good for women’s health and is therefore something they should do for the long term."

At the core of this woman-centred approach is an understanding of the psychosocial context of women’s smoking. Women who smoke while pregnant are primarily young – often under 25, many of them lone mothers, living in poverty or on fixed incomes. “They’re a different group from those the original smoking campaigns targeted 20 years ago,” says Greaves. “Those were for people with options or the money or opportunity to do other things.” Pregnant women who quit spontaneously tend to be older, better educated and less likely to have partners who smoke.

Research has also found that women from disadvantaged backgrounds are more likely to take their cues about the health risks of smoking from people in their social circles and families. Louise Guyon, a researcher with the Institut national de santé publique du Québec in Ste-Foy, found that, for these women, their mothers’ opinions on tobacco use during pregnancy carried the most weight, whether they were encouraging their daughters to quit or minimizing the dangers. And even though the women knew that tobacco use during pregnancy is harmful, the majority didn’t understand why.

But even among women who understand the risks, smoking may reflect other issues in the woman’s life. According to Rosa Dragonetti, manager of the Nicotine Dependence Clinic at the Centre for Addiction and Mental Health (CAMH) in Toronto, pregnancy and new motherhood can bring past trauma to the surface. Partner abuse may continue, escalate or actually begin during pregnancy. Poor mental health, particularly depression, may be a stressor. "These things lead some women to smoke in the first place," says Dragonetti, "so smoking is one of their coping skills. If you take that away, how are they going to cope?"

Adding another layer of complexity is the smoking environment in which the woman lives. Partners’ reactions and smoking status influence women’s ability to quit. One key risk factor for postpartum smoking relapse is having a partner who smokes. Dr. Joan Bottorff, chair of health promotion and cancer prevention at the University of British Columbia in Vancouver, found that women’s tobacco use during pregnancy was a source of tension for some couples. Yet most of the male partners who smoked did not consider changing their own habits. Indeed, some taunted their partners – I can smoke and you can’t – smoked in their presence and left cigarettes in plain view with­out thinking of the temptation. “When people pressured these women, including their partners, they didn’t appreciate it,” says Bottorff. “They wanted to make their own decisions about stopping smoking and do it on their own terms.”

Given the multiple challenges in quitting and staying quit, Greaves says interventions for pregnant women and new mothers must be comprehensive, holistic and sympathetic. "We can’t just say, 'Here are 10 handy tips for quitting – go for it.' We need to start pre-pregnancy with woman-positive messages that send help, support and value to women as individuals around quitting smoking. We need to discuss these issues not just with women but with doctors and nurses. We also need to segment our approach to reach low-income women, girls and other high-risk groups. And relapse prevention has to be on the agenda."

Comprehensive intervention strategies for smoking cessation/reduction in pregnant women and new mothers may involve four levels of intervention. The first level involves raising public awareness of the health risks of women’s smoking and framing the messages in sensitive, non-judgmental ways that focus on women’s health. The second level involves discussing smoking and related risks with all women and girls of childbearing age and with key members of their health and social networks, especially partners and mothers.

Level three encompasses specialized, accessible services for pregnant women who smoke and tailoring them to women’s social, psychological and economic circumstances. Fourth-level interventions provide postpartum support to new mothers to help them maintain or initiate changes in tobacco use, improve their health and social support and enhance the health of their children.

Here are three Canadian programs taking a unique approach to providing women-centred interventions.

PREGNETS: Prevention of Gestational and Neonatal Exposure to Tobacco Smoke

The PREGNETS network of tobacco control and prenatal care providers has trained health professionals to deliver brief interventions that consist primarily of asking pregnant women if they smoke, advising smokers to think about changing some of their behaviours and referring women to resources such as the Canadian Cancer Society’s Smokers’ Helpline and Motherisk, whose staff have been trained by PREGNETS. The program has also shown Canada prenatal nutrition program projects in Ontario how to integrate smoking cessation messages without alienating pregnant smoking women. The web site, which was created as a resource for health providers, now includes a moderated discussion/support group for pregnant and postpartum women. "Pregnant women don’t typically attend smoking cessation groups because of stigma," says project co-ordinator Dragonetti at CAMH. "This online group provides a confidential way to participate and get support."

STARSS: Start Thinking About Reducing Second-hand Smoke

This Health Canada-funded harm reduction support strategy helps low-income mothers identify small, measurable steps they can take to protect their children from second-hand smoke, for example, delaying smoking, reducing one cigarette a day, smoking outdoors once a day. By building skills, the program helps women gain the confidence to take larger steps. "STARSS is not for women who are ready to quit; it is for women who smoke and don’t have the self-efficacy to consider quitting," says Wendy Reynolds, executive director of AWARE (Action on Women’s Addictions-Research and Education), which developed STARSS. AWARE also offers Breath of Fresh Air, which provides low-income single mothers who want to quit with free smoking cessation aids. AWARE is also developing a training guide for smoking interventions with women with fetal alcohol spectrum disorder.

TRIPs: Tobacco-Related Interaction Patterns

Couples and Smoking: What You Need to Know When You Are Pregnant is an information booklet designed to educate pregnant women about how their smoking is influenced by their partners and every­day routines. Developed as part of ActNow BC: Healthy Choices in Pregnancy, the booklet is being launched this fall. A related smoking cessation intervention is being developed to support tobacco reduction in new fathers (see FACET in Resources sidebar). The first of its kind, the program will build on research findings on new fathers’ smoking patterns – the changes or modifications they make after the baby is born, their reduction or quit attempts and successful quit strategies. “If we could get men to reduce or stop smoking, that would support postpartum women in maintaining their quit and ensuring their children are protected from second­hand smoke,” says Bottorff.

 

• Print Share