- Email: [email protected]
Can we modify the enrollment in a postpartum smoking cessation intervention in Spain?
Midwifery 30 (2014) 427–431
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Can we modify the enrollment in a postpartum smoking cessation intervention in Spain? Isabel Nerín, PhD, MD (Prof. Lecturer)a,b,n, Adriana Jiménez-Muro, PhD (Assistant Professor)c, Pilar Samper, PhD, MD (Prof. Lecturer)d, Adriana Marqueta, PhD (Psychologist)a, Pilar Gargallo, PhD (Prof. Lecturer)e, Asunción Beamonte, PhD (Prof. Lecturer)e, Gerardo Rodríguez, PhD, MD (Prof. Lecturer)d,f,g a
Tobacco Control Unit, University of Zaragoza, Spain Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Spain Departament of Psychology and Sociology, University of Zaragoza, Spain d Department of Paediatrics, Radiology and Physical Medicine, University of Zaragoza, Spain e Department of Statistical Methods, University of Zaragoza, Spain f Hospital Clínico Universitario ‘Lozano Blesa’, Zaragoza, Spain g Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain b c
art ic l e i nf o
a b s t r a c t
Article history: Received 12 September 2012 Received in revised form 19 April 2013 Accepted 21 April 2013
Objective: it is known that very few women who continue to smoke at the time of delivery stop smoking during the postpartum period. Discovering strategies that can be incorporated during pregnancy to help improve women's participation in postpartum interventions could increase the number of women nonsmokers. The aim of this study is to identify the predictors of participation by pregnant women smokers in a postpartum smoking cessation intervention. Design: a cross-sectional study was carried out amongst women smokers who had attended to give birth. Setting: women attended the University Clinical Hospital ‘Lozano Blesa’ of Zaragoza (Spain) who were smokers before pregnancy and reported at delivery to have continued smoking during pregnancy were eligible and were invited to participate in the study. Findings: 2044 women completed the questionnaire 24 hours after giving birth. The smoking prevalence during pregnancy was 18.2% (n ¼372) and 62.9% of them (n ¼234) participated. The logistic regression model provided five significant predictors for women who participated: intention to breast feed, having less of an urge to smoke the first cigarette of the day before pregnancy, having reduced consumption during pregnancy by 50% or more, having received advice and being willing to get help. Conclusions and implications for the practice: the factors associated with participation show aspects that can be modified by maternal and child health professionals. Advice to stop smoking, received during pregnancy, encourages participation in a postpartum intervention. From the point of view of public health, the huge increase in the prevalence of smoking women poses the need to take advantage of the pregnancy as an opportunity for giving up smoking definitely. It would be necessary to identify what programmes of smoking cessation have better results in pregnant women and to know how to motivate health professionals to implement them. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Smoking cessation Pregnancy Relapse Post partum
Introduction Smoking during pregnancy increases the risk of adverse health outcomes for the mother and fetus (U.S. Department of Health and Human Services, 2001). Despite this, approximately half of women n Corresponding author at: Unidad de Tabaquismo FMZ, Facultad de Medicina, Universidad de Zaragoza, C/ Domingo Miral s/n. Aulario A, 1a planta, 50009 Zaragoza, Spain. E-mail address: [email protected] (I. Nerín).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.04.006
smokers continue to smoke during pregnancy. In high-income countries, an estimated 6–22% of women smoke during pregnancy and, at the moment of delivery, smoking prevalence in pregnant women remains high (Nichter et al., 2010). The postpartum period is considered to be a window of opportunity for preventive interventions to introduce healthy behaviours because there is contact with maternal and child health professionals for an extended period of time (McBride et al., 2003; Hoedjes et al., 2010). Postpartum smoking exposes the infant to Second-Hand Smoke (SHS), which is associated with
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I. Nerín et al. / Midwifery 30 (2014) 427–431
a range of health problems in children, including a higher risk of sudden infant death syndrome, acute respiratory infections, ear infections, and more severe asthma (Department of Health and Human Services, 2006; López et al., 2008). In addition, the mother also exposes herself to the health risks associated with continuing to smoke. Some interventions during post partum has been proposed in the past few years to get better smoking cessation rates in women, but it has been suggested to use more effective motivational approaches to achieve consistent behaviour change (Ershoff et al., 2000). Proactive interventions during post partum, using resources on Motivational Interviewing (MI) and relapse prevention may reduce the probability of relapse in recent quitters and helps female smokers to make progress in the behavioural process of change (Jiménez-Muro et al., 2013). The majority of smoking cessation postpartum interventions have had limited participation, between 50% and 70%, because it is difficult to recruit pregnant women to this type of study (Ruggiero et al., 2003). Some barriers have been described like ‘lack of time’ (Ussher et al., 2006) or a decreasing interest after having a healthy newborn because the mothers are less aware of the adverse effects of SHS on their infants (Ashford et al., 2010). Discovering strategies that can be incorporated during pregnancy to improve women's participation in postpartum interventions could achieve better results and increase the number of non-smoking women. The aim of this study was to identify the predictors of participation by pregnant women smokers in a postpartum smoking cessation intervention in Spain.
Methods Design and study setting This is a cross-sectional study in pregnant smokers, which is part of the main study designed as a randomised controlled trial (RCT). The RCT was a population-based intervention study designed for women at the end of pregnancy. Motivational interviewing and relapse prevention was used to achieve the aims of this intervention (Miller and Rollnick, 2002). The target population was women who attended the University Clinical Hospital ‘Lozano Blesa’ of Zaragoza (Spain) to give birth between January 2009 and March 2010. All women were asked to complete a structured questionnaire to determine sociodemographic characteristics and smoking behaviour during pregnancy. We designed a questionnaire on smoking, after reviewing the literature, since there was not a previous model to collect all aspects included in this study. All women were asked to complete the structured questionnaire and the interviews were conducted 24 hours after giving birth by the same person. The inclusion criteria for the intervention study were: to be a current smoker (having smoked during pregnancy) or a recent quitter (having stopped smoking at the beginning or during pregnancy) and agree to participate; women included in the study were randomly assigned to one of the two groups (control and intervention). Measurements and results of smoking cessation intervention have been published elsewhere (JiménezMuro et al., 2013). For the present study we only included those women that had smoked during pregnancy and were smokers at the point of giving birth. Women who reported having stopped smoking during pregnancy were excluded. Data collection The sociodemographic variables studied were age, nationality, employment status and educational level; the pregnancy-related
variables were parity and self-reported intention to breast feed; the smoking-related variables considered were age at onset and the two items from the Fagerström Test that best reflect nicotine dependence: cigarettes smoked daily and time until the first cigarette of the day (‘less than 30 minutes’ or ‘more than 30 minutes’) before pregnancy. In all women smokers who said that they had reduced their consumption during pregnancy we calculated the decrease using the following formula: [(cigarettes smoked daily before pregnancy−cigarettes smoked daily during pregnancy)/cigarettes smoked daily before pregnancy] 100. The reduction was then classified into two categories: ‘reduced by 50% or more’ or ‘reduced by less than 50%’. The smoking status was determined by self-reporting and carbon monoxide (CO) in exhaled air (less than 6 ppm to be considered a non-smoker). The perception of risk to SHS and exposure of the newborn (NB) was assessed using the categories ‘none’, ‘little’, ‘moderate’ and ‘high’. These variables were combined into two categories in the subsequent analysis: none and little into ‘low perception’ and moderate and high into ‘high perception’. All women were asked whether they had received advice to stop smoking during pregnancy (‘It is very important to stop smoking for your health and your baby’) and whether they would be willing to get help to stop smoking. The Clinics Ethics Committee authorised this research and written informed consent was obtained from every woman. Data analysis A descriptive analysis was performed for the total sample, and also separately for the two groups of women: those who participated and those who did not participate. These groups were compared using a bivariable analysis by means of an ANOVA test and χ2. The level of statistical significance was established at a two-sided p-value of less than 0.05. A multivariable analysis was performed by using a binary logistic regression model including all significant variables in the bivariable analysis except the variables ‘Cigarettes smoked daily before pregnancy’ and ‘Cigarettes smoked daily during pregnancy’ because they could have an interaction with the variable ‘Reduction by 50%’. In this model the outcome variable was whether the woman participated or not in the intervention.
Findings A total of 2044 women answered the questionnaire 24 hours after given birth. The smoking prevalence at the time of giving birth was 18.2% (n ¼372); 62.9% of them (n ¼234) agreed to participated and 37.1% (n¼ 138) did not agree to participate in the postpartum smoking cessation intervention (Fig. 1). Characteristics of women who still smoke at the time of giving birth are in Table 1. A percentage of 95.3% (359) reduced their consumption during pregnancy: 66.1% (246) reduced their consumption 50% or more and 33.9% (126) less than 50%. Women who reduced by 50% or more had CO levels of 3.84 ppm compared to those who reduced by less than 50% with CO levels of 6.06 ppm (p o0.001). The women who agreed to participate in the postpartum smoking cessation intervention were more likely employed, had a higher educational level and were more likely to intend to breast feed. They smoked, prior to becoming pregnant, fewer cigarettes daily, had less of an urge to smoke their first cigarette of the day and had reduced consumption by 50% or more during pregnancy. They had a higher perception of the risk of exposure to SHS, received advice to stop smoking during pregnancy and were willing to get help (Table 1).
I. Nerín et al. / Midwifery 30 (2014) 427–431
Analysing the bivariable logistic regression model (Table 2) we obtained the probability of accept to participate or not in the postpartum smoking cessation intervention related to different factors: being employed, having primary or higher education level, intention to breast feed, having less of an urge to smoke their first cigarette of the day before pregnancy, reducing consumption during pregnancy by 50% or more, having a higher perception of
429
risk, receiving advice to stop smoking and being willing to get help. When the logistic regression was adjusted for all the significant variables, the predictor variables to participate in the postpartum smoking cessation were: intention to breast feed, having less of an urge to smoke their first cigarette of the day before pregnancy, having reduced consumption during pregnancy by 50% or more, having received advice to stop smoking and being willing to get help (Table 2).
2044 women completed the questionnaire
Discussion 30.6% (626/2044) women smoked before pregnancy
40.5% (254/626) women stopped smoking during pregnancy (excluded)
SAMPLE OF THIS STUDY 18.2% (372/2044) smoked during pregnancy
37.1% (138/372) women not agree to participate
62.9% (234/372) women agree to participate
Fig. 1. Diagram showing the flow of participants in the present cross-sectional study about agree or not in the participation of the postpartum smoking cessation intervention.
Our results show that intention to participate in a smoking cessation programme during the postpartum period is associated with receiving advice to stop smoking during gestation, intended to breast feed, the reduction in cigarette consumption during pregnancy and the willingness to receive help to quit smoking, all aspects modifiable by professionals during the antenatal period. By contrast, the level of nicotine dependence before pregnancy is associated with less intention to participate in the postpartum smoking cessation intervention. There is one predictive factor that is particularly difficult to modify in smoking pregnant women and it has shown to be a significant barrier to cessation: nicotine dependence (Diclemente et al., 2000). As we can see in the results, women who did not agree to participate in cessation intervention smoked more cigarettes (18.7 versus 16.3) and they had more urge to smoke their first cigarette of the day than women who agree to participate;
Table 1 Sample characteristics and results of bivariable analysis Total 100%(372) % (n)
Age (years) Nationality Spanish Non-Spanish Employment Status Employed Unemployed Educational level Less than primary and primary Secondary University Parity Primiparous Multiparous Intention to breastfeed Yes No Age at onset (years) Cigarettes smoked daily before pregnancy Time to smoke 1st cigarette of the day before pregnancy Less than 30' More than 30' Cigarettes smoked daily during pregnancy Reduction 50 % or more No Yes Perception of risk Low High Advice received Yes No Willingness to get help Positive Negative NS: Not significant a
Mean (SD)
30.0 (5.5)
a
Not agree to participate 37.1% (138) % (n) 30.3 (5.6)
a
Agree to participate 62.9% (234) % (n) 29.9 (5.4)
a
p
NS
80.9 (301) 19.1 (71)
84.8 (117) 15.2 (21)
78.6 (184) 21.4 (50)
NS
64.5 (240) 35.5 (132)
58 (80) 42 (58)
68.4 (160) 31.6 (74)
0.043
55.9 (208) 28.2 (105) 15.9 (59)
65.9 (91) 21 (29) 13 (18)
50 (117) 32.5 (76) 17.5 (41)
0.011
55.6 (207) 44.4 (165)
53.6 (74) 46.4 (64)
56.8 (133) 43.2 (101)
NS
84.1 (313) 15.9 (59) 15.5 (2.9) a 17.2 (5.1) a
73.2 (101) 26.8 (37) 15.5 (3.2) a 18.7 (4.7) a
90.6 (212) 9.4 (22) 15.6 (2.8) a 16.3 (5.2)a
0.001 NS 0.001
72.3 (269) 27.7 (103) 7.9 (5.2) a
80.4 (111) 19.6 (27) 12.9 (4.8) a
67.5 (158) 32.5 (76) 4.9 (2.5)a
0.007 0.001
33.9 (126) 66.1 (246)
72.5 (100) 27.5 (38)
11.1 (26) 88.9 (208)
0.001
31.2 (116) 68.8 (256)
42 (58) 58 (80)
24.8 (58) 75.2 (176)
0.001
50.8 (189) 49.2 (183)
14.5 (20) 85.5 (118)
72.2 (169) 27.8 (65)
0.001
67.2 (250) 32.8 (122)
41.3 (57) 58.7 (81)
82.5 (193) 17.5 (41)
0.001
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I. Nerín et al. / Midwifery 30 (2014) 427–431
Table 2 Summary of the logistic regression model of predictors of participation in a postpartum smoking cessation intervention. Crude data
Adjusted data
OR
CI 95%
OR
CI 95%
Employment status Employed Unemployed
1.00 0.638
(0.412–0.987)n
1.00 1.019
(0.445–2.333)
Educational level Less than primary and primary Secondary University
1.00 2.038 1.772
(1.226–3.388)n (0.955–3.287)
1.00 0.885 0.996
(0.361–2.170) (0.372–2.669)
Intention to breast feed No Yes
1.00 3.530
(1.980–6.295)nnn
1.00 4.120
(1.457–11.649)nnn
(1.197–3.266)n
1.00 2.538
(1.051–6.132)n
Time to smoke first cigarette of the day before pregnancy Less than 30′ 1.00 More than 30′ 1.997 Reduction 50% or more No Yes Perception of risk Low High Advice received No Yes Willingness to get help Negative Positive
1.00 21.053
(12.111–36.596)nnn
1.00 33.477
1.00 2.200
(1.403–3.450)nn
1.00 15.340
(8.819–26.684)nnn
1.00 20.152
(8.733–46.504)nnn
1.00 6.689
(4.148–10.788)nnn
1.00 10.894
(4.753–24.972)nnn
1.00 0.996
(14.228–78.766)nnn
(0.439–2.259)
OR: odds ratio. CI 95%: 95% confidence interval. Adjusted data: for all significant variables in the binary logistic regression model except the variables ‘Cigarettes smoked daily before pregnancy’ and ‘Cigarettes smoked daily during pregnancy’. R2 de Nagelkerke: 0.739. n
p o 0.05. p o0.01. po 0.001.
nn
nnn
both variables are indicative of a higher level of nicotine dependence in the group that did not accept to participate. In contrast, other predictive factors found in our study can be modified by health-care staff and included in the smoking cessation interventions during pregnancy. Our results, like those from DiSantis et al. (2010), show that breast feeding has a protective effect on postpartum smoking. For that reason, it is important to combine both counselling topics (to breast feed and to stop smoking) earlier in the antenatal period. Therefore, it is necessary to systematically incorporate a recommendation to stop smoking in obstetric, antenatal and paediatric protocols, because some studies have shown that it is not made as routine (Winickoff et al., 2010), and this should be given as strongly as breast-feeding recommendations due to the benefits already known (McBride et al., 2003; Ripley-Moffitt et al., 2008). Almost half of the pregnant smokers (49.2%) were not given advice to stop smoking during pregnancy (Table 1), a higher percentage than reported by Park et al. (2009), and those who were given advice participated in a higher proportion in the postpartum smoking cessation intervention (OR: 20.152; IC 95%: 8.733–46.504) (Table 2). Thus, advice should be accompanied by specific information concerning the risk of SHS exposure because a third of the total sample (31,2%) had a low perception of this risk (Table 1). A further aspect that can be modified by health-care staff is to be proactive (always offering smoking cessation support to women at all maternal and child health visits) in order to take advantage of all cessation opportunities (Condliffe et al., 2005; Pollack et al., 2006; López et al., 2008). It is well known that this is
much more effective than being reactive (waiting for women to request help themselves and contacting the appropriate support staff to do so). Moreover, being proactive could be connected to the willingness to get help to stop smoking in women. In order to assess the reduction we established two categories (50% or more and less than 50%). The CO levels were measured in each woman and both groups had low CO levels, but with significant differences between them. This biomarker is reasonably specific for detecting heavy cigarette smoking but is of marginal use in detecting light smoking (SRNT Subcommittee on Biochemical Verification, 2002), which was the case of these women. These women are smokers of fewer cigarettes (7.9 cigarettes per day during pregnancy) (Table 1) and the cooximetry was obtained after delivery, when they had been hospitalised for a few days (24–72 hours) and therefore take days without smoking. Both factors contribute to obtain low levels of CO (similar to non-smokers); however, the aim to measure the CO was really to evaluate the difference between both groups, not to measure the smoking habit. To stop smoking is the safest action to minimise the risks of pregnancy and postpartum complications in both newborns and women. A reduction in tobacco consumption suggests that there may be a greater concern about health or also a greater willingness to get help than in case of women who do not have reduced. In fact, those who reduced their consumption by more than 50% accepted to participate in the cessation programme in a higher proportion. The advice given to pregnant and postpartum smokers must be to quit completely instead of reducing the consumption. However due to the effects in the health of newborn is dose
I. Nerín et al. / Midwifery 30 (2014) 427–431
dependent, some women may think that reducing the number of cigarettes is a healthier option. The percentage of participation in our study (62.9%) is close to that achieved in other studies involving similar interventions during post partum (Ruggiero et al., 2003; Hennrikus et al., 2010). In order to improve participation in these smoking cessation interventions it has been proposed the use of additional resources such as incentives, home visits, repeated telephone calls, email and postal contacts, among others (Lumley et al., 2009). Moreover, many of the studies which analysed the participation of pregnant women in smoking cessation interventions were focused on groups with specific sociocultural characteristics (ethnic minorities or low income women) (Curry et al., 2001; Giglia et al., 2007). This study is part of a RCT to evaluate the efficacy of a behavioural intervention in a population of pregnant women and the aim was to identify strategies that could be incorporated into the daily clinical practice without increasing human and economic resources in a general population of pregnant women. The study can be considered to have some limitations, such as the local sample population from only one hospital in a single country. However, the problem with smoking during pregnancy has been detected in other countries and is quite common (López et al., 2008; Diclemente et al., 2000; Park et al., 2009). Other limitation is the measurement of CO, because the CO level is not the best biomarker for the continuous active exposure during pregnancy in these smoking women, but it helps us to validate the self-declaration of the reduction and to discriminate between those who reduced more than 50% and those who did not (Pickett et al., 2005). Therefore in this study the aim to measure the CO level was to evaluate the reduction not the smoking habit. Another limitation could be the influence of memory bias when analysing what has happened during pregnancy retrospectively. Regarding the number of cigarettes smoked per day, as has already been documented women that smoke when pregnant feel guilty and, in some cases, under-report their consumption. However, we consider that there was no under-reported consumption interviewing women after having a healthy child. In conclusion, a significant number of smoker women still refuse to participate in smoking cessation programmes in the post partum. As recommendations for practice it is necessary to know that there are some aspects that could be modified by health professionals into the routine care, without increasing the resources, to improve the participation in these interventions. First of all, proactive smoking cessation programmes before, during and after pregnancy should be planned to all smoking women. In addition, the advice to quit smoking, together with information regarding the risks of SHS exposure, should be systematically included in routine mother/child health visits. This information must be given combined with the recommendation of breast feeding and with the same intensity. From the point of view of public health, the huge increase in the prevalence of smoking women poses the need to take advantage of the pregnancy as an opportunity for giving up smoking definitely. It would be necessary to identify what programmes of smoking cessation have better results in pregnant women and to know how to motivate health professionals to implement them. Conflict of interests The authors report no conflicts of interests. Acknowledgements This work was supported by the Ministry of Health and Consumer Affairs: “Evaluation of Healthcare Technologies” (PI 08/90705 IACS,
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Aragon Health Sciences Institute) and “Maternal, Child Health and Development Network” (RD08/0072). Spanish National Research Programme (2008–2011).
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Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Can we modify the enrollment in a postpartum smoking cessation intervention in Spain? Isabel Nerín, PhD, MD (Prof. Lecturer)a,b,n, Adriana Jiménez-Muro, PhD (Assistant Professor)c, Pilar Samper, PhD, MD (Prof. Lecturer)d, Adriana Marqueta, PhD (Psychologist)a, Pilar Gargallo, PhD (Prof. Lecturer)e, Asunción Beamonte, PhD (Prof. Lecturer)e, Gerardo Rodríguez, PhD, MD (Prof. Lecturer)d,f,g a
Tobacco Control Unit, University of Zaragoza, Spain Department of Medicine, Psychiatry and Dermatology, University of Zaragoza, Spain Departament of Psychology and Sociology, University of Zaragoza, Spain d Department of Paediatrics, Radiology and Physical Medicine, University of Zaragoza, Spain e Department of Statistical Methods, University of Zaragoza, Spain f Hospital Clínico Universitario ‘Lozano Blesa’, Zaragoza, Spain g Instituto Aragonés de Ciencias de la Salud, Zaragoza, Spain b c
art ic l e i nf o
a b s t r a c t
Article history: Received 12 September 2012 Received in revised form 19 April 2013 Accepted 21 April 2013
Objective: it is known that very few women who continue to smoke at the time of delivery stop smoking during the postpartum period. Discovering strategies that can be incorporated during pregnancy to help improve women's participation in postpartum interventions could increase the number of women nonsmokers. The aim of this study is to identify the predictors of participation by pregnant women smokers in a postpartum smoking cessation intervention. Design: a cross-sectional study was carried out amongst women smokers who had attended to give birth. Setting: women attended the University Clinical Hospital ‘Lozano Blesa’ of Zaragoza (Spain) who were smokers before pregnancy and reported at delivery to have continued smoking during pregnancy were eligible and were invited to participate in the study. Findings: 2044 women completed the questionnaire 24 hours after giving birth. The smoking prevalence during pregnancy was 18.2% (n ¼372) and 62.9% of them (n ¼234) participated. The logistic regression model provided five significant predictors for women who participated: intention to breast feed, having less of an urge to smoke the first cigarette of the day before pregnancy, having reduced consumption during pregnancy by 50% or more, having received advice and being willing to get help. Conclusions and implications for the practice: the factors associated with participation show aspects that can be modified by maternal and child health professionals. Advice to stop smoking, received during pregnancy, encourages participation in a postpartum intervention. From the point of view of public health, the huge increase in the prevalence of smoking women poses the need to take advantage of the pregnancy as an opportunity for giving up smoking definitely. It would be necessary to identify what programmes of smoking cessation have better results in pregnant women and to know how to motivate health professionals to implement them. & 2013 Elsevier Ltd. All rights reserved.
Keywords: Smoking cessation Pregnancy Relapse Post partum
Introduction Smoking during pregnancy increases the risk of adverse health outcomes for the mother and fetus (U.S. Department of Health and Human Services, 2001). Despite this, approximately half of women n Corresponding author at: Unidad de Tabaquismo FMZ, Facultad de Medicina, Universidad de Zaragoza, C/ Domingo Miral s/n. Aulario A, 1a planta, 50009 Zaragoza, Spain. E-mail address: [email protected] (I. Nerín).
0266-6138/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.midw.2013.04.006
smokers continue to smoke during pregnancy. In high-income countries, an estimated 6–22% of women smoke during pregnancy and, at the moment of delivery, smoking prevalence in pregnant women remains high (Nichter et al., 2010). The postpartum period is considered to be a window of opportunity for preventive interventions to introduce healthy behaviours because there is contact with maternal and child health professionals for an extended period of time (McBride et al., 2003; Hoedjes et al., 2010). Postpartum smoking exposes the infant to Second-Hand Smoke (SHS), which is associated with
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I. Nerín et al. / Midwifery 30 (2014) 427–431
a range of health problems in children, including a higher risk of sudden infant death syndrome, acute respiratory infections, ear infections, and more severe asthma (Department of Health and Human Services, 2006; López et al., 2008). In addition, the mother also exposes herself to the health risks associated with continuing to smoke. Some interventions during post partum has been proposed in the past few years to get better smoking cessation rates in women, but it has been suggested to use more effective motivational approaches to achieve consistent behaviour change (Ershoff et al., 2000). Proactive interventions during post partum, using resources on Motivational Interviewing (MI) and relapse prevention may reduce the probability of relapse in recent quitters and helps female smokers to make progress in the behavioural process of change (Jiménez-Muro et al., 2013). The majority of smoking cessation postpartum interventions have had limited participation, between 50% and 70%, because it is difficult to recruit pregnant women to this type of study (Ruggiero et al., 2003). Some barriers have been described like ‘lack of time’ (Ussher et al., 2006) or a decreasing interest after having a healthy newborn because the mothers are less aware of the adverse effects of SHS on their infants (Ashford et al., 2010). Discovering strategies that can be incorporated during pregnancy to improve women's participation in postpartum interventions could achieve better results and increase the number of non-smoking women. The aim of this study was to identify the predictors of participation by pregnant women smokers in a postpartum smoking cessation intervention in Spain.
Methods Design and study setting This is a cross-sectional study in pregnant smokers, which is part of the main study designed as a randomised controlled trial (RCT). The RCT was a population-based intervention study designed for women at the end of pregnancy. Motivational interviewing and relapse prevention was used to achieve the aims of this intervention (Miller and Rollnick, 2002). The target population was women who attended the University Clinical Hospital ‘Lozano Blesa’ of Zaragoza (Spain) to give birth between January 2009 and March 2010. All women were asked to complete a structured questionnaire to determine sociodemographic characteristics and smoking behaviour during pregnancy. We designed a questionnaire on smoking, after reviewing the literature, since there was not a previous model to collect all aspects included in this study. All women were asked to complete the structured questionnaire and the interviews were conducted 24 hours after giving birth by the same person. The inclusion criteria for the intervention study were: to be a current smoker (having smoked during pregnancy) or a recent quitter (having stopped smoking at the beginning or during pregnancy) and agree to participate; women included in the study were randomly assigned to one of the two groups (control and intervention). Measurements and results of smoking cessation intervention have been published elsewhere (JiménezMuro et al., 2013). For the present study we only included those women that had smoked during pregnancy and were smokers at the point of giving birth. Women who reported having stopped smoking during pregnancy were excluded. Data collection The sociodemographic variables studied were age, nationality, employment status and educational level; the pregnancy-related
variables were parity and self-reported intention to breast feed; the smoking-related variables considered were age at onset and the two items from the Fagerström Test that best reflect nicotine dependence: cigarettes smoked daily and time until the first cigarette of the day (‘less than 30 minutes’ or ‘more than 30 minutes’) before pregnancy. In all women smokers who said that they had reduced their consumption during pregnancy we calculated the decrease using the following formula: [(cigarettes smoked daily before pregnancy−cigarettes smoked daily during pregnancy)/cigarettes smoked daily before pregnancy] 100. The reduction was then classified into two categories: ‘reduced by 50% or more’ or ‘reduced by less than 50%’. The smoking status was determined by self-reporting and carbon monoxide (CO) in exhaled air (less than 6 ppm to be considered a non-smoker). The perception of risk to SHS and exposure of the newborn (NB) was assessed using the categories ‘none’, ‘little’, ‘moderate’ and ‘high’. These variables were combined into two categories in the subsequent analysis: none and little into ‘low perception’ and moderate and high into ‘high perception’. All women were asked whether they had received advice to stop smoking during pregnancy (‘It is very important to stop smoking for your health and your baby’) and whether they would be willing to get help to stop smoking. The Clinics Ethics Committee authorised this research and written informed consent was obtained from every woman. Data analysis A descriptive analysis was performed for the total sample, and also separately for the two groups of women: those who participated and those who did not participate. These groups were compared using a bivariable analysis by means of an ANOVA test and χ2. The level of statistical significance was established at a two-sided p-value of less than 0.05. A multivariable analysis was performed by using a binary logistic regression model including all significant variables in the bivariable analysis except the variables ‘Cigarettes smoked daily before pregnancy’ and ‘Cigarettes smoked daily during pregnancy’ because they could have an interaction with the variable ‘Reduction by 50%’. In this model the outcome variable was whether the woman participated or not in the intervention.
Findings A total of 2044 women answered the questionnaire 24 hours after given birth. The smoking prevalence at the time of giving birth was 18.2% (n ¼372); 62.9% of them (n ¼234) agreed to participated and 37.1% (n¼ 138) did not agree to participate in the postpartum smoking cessation intervention (Fig. 1). Characteristics of women who still smoke at the time of giving birth are in Table 1. A percentage of 95.3% (359) reduced their consumption during pregnancy: 66.1% (246) reduced their consumption 50% or more and 33.9% (126) less than 50%. Women who reduced by 50% or more had CO levels of 3.84 ppm compared to those who reduced by less than 50% with CO levels of 6.06 ppm (p o0.001). The women who agreed to participate in the postpartum smoking cessation intervention were more likely employed, had a higher educational level and were more likely to intend to breast feed. They smoked, prior to becoming pregnant, fewer cigarettes daily, had less of an urge to smoke their first cigarette of the day and had reduced consumption by 50% or more during pregnancy. They had a higher perception of the risk of exposure to SHS, received advice to stop smoking during pregnancy and were willing to get help (Table 1).
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Analysing the bivariable logistic regression model (Table 2) we obtained the probability of accept to participate or not in the postpartum smoking cessation intervention related to different factors: being employed, having primary or higher education level, intention to breast feed, having less of an urge to smoke their first cigarette of the day before pregnancy, reducing consumption during pregnancy by 50% or more, having a higher perception of
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risk, receiving advice to stop smoking and being willing to get help. When the logistic regression was adjusted for all the significant variables, the predictor variables to participate in the postpartum smoking cessation were: intention to breast feed, having less of an urge to smoke their first cigarette of the day before pregnancy, having reduced consumption during pregnancy by 50% or more, having received advice to stop smoking and being willing to get help (Table 2).
2044 women completed the questionnaire
Discussion 30.6% (626/2044) women smoked before pregnancy
40.5% (254/626) women stopped smoking during pregnancy (excluded)
SAMPLE OF THIS STUDY 18.2% (372/2044) smoked during pregnancy
37.1% (138/372) women not agree to participate
62.9% (234/372) women agree to participate
Fig. 1. Diagram showing the flow of participants in the present cross-sectional study about agree or not in the participation of the postpartum smoking cessation intervention.
Our results show that intention to participate in a smoking cessation programme during the postpartum period is associated with receiving advice to stop smoking during gestation, intended to breast feed, the reduction in cigarette consumption during pregnancy and the willingness to receive help to quit smoking, all aspects modifiable by professionals during the antenatal period. By contrast, the level of nicotine dependence before pregnancy is associated with less intention to participate in the postpartum smoking cessation intervention. There is one predictive factor that is particularly difficult to modify in smoking pregnant women and it has shown to be a significant barrier to cessation: nicotine dependence (Diclemente et al., 2000). As we can see in the results, women who did not agree to participate in cessation intervention smoked more cigarettes (18.7 versus 16.3) and they had more urge to smoke their first cigarette of the day than women who agree to participate;
Table 1 Sample characteristics and results of bivariable analysis Total 100%(372) % (n)
Age (years) Nationality Spanish Non-Spanish Employment Status Employed Unemployed Educational level Less than primary and primary Secondary University Parity Primiparous Multiparous Intention to breastfeed Yes No Age at onset (years) Cigarettes smoked daily before pregnancy Time to smoke 1st cigarette of the day before pregnancy Less than 30' More than 30' Cigarettes smoked daily during pregnancy Reduction 50 % or more No Yes Perception of risk Low High Advice received Yes No Willingness to get help Positive Negative NS: Not significant a
Mean (SD)
30.0 (5.5)
a
Not agree to participate 37.1% (138) % (n) 30.3 (5.6)
a
Agree to participate 62.9% (234) % (n) 29.9 (5.4)
a
p
NS
80.9 (301) 19.1 (71)
84.8 (117) 15.2 (21)
78.6 (184) 21.4 (50)
NS
64.5 (240) 35.5 (132)
58 (80) 42 (58)
68.4 (160) 31.6 (74)
0.043
55.9 (208) 28.2 (105) 15.9 (59)
65.9 (91) 21 (29) 13 (18)
50 (117) 32.5 (76) 17.5 (41)
0.011
55.6 (207) 44.4 (165)
53.6 (74) 46.4 (64)
56.8 (133) 43.2 (101)
NS
84.1 (313) 15.9 (59) 15.5 (2.9) a 17.2 (5.1) a
73.2 (101) 26.8 (37) 15.5 (3.2) a 18.7 (4.7) a
90.6 (212) 9.4 (22) 15.6 (2.8) a 16.3 (5.2)a
0.001 NS 0.001
72.3 (269) 27.7 (103) 7.9 (5.2) a
80.4 (111) 19.6 (27) 12.9 (4.8) a
67.5 (158) 32.5 (76) 4.9 (2.5)a
0.007 0.001
33.9 (126) 66.1 (246)
72.5 (100) 27.5 (38)
11.1 (26) 88.9 (208)
0.001
31.2 (116) 68.8 (256)
42 (58) 58 (80)
24.8 (58) 75.2 (176)
0.001
50.8 (189) 49.2 (183)
14.5 (20) 85.5 (118)
72.2 (169) 27.8 (65)
0.001
67.2 (250) 32.8 (122)
41.3 (57) 58.7 (81)
82.5 (193) 17.5 (41)
0.001
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Table 2 Summary of the logistic regression model of predictors of participation in a postpartum smoking cessation intervention. Crude data
Adjusted data
OR
CI 95%
OR
CI 95%
Employment status Employed Unemployed
1.00 0.638
(0.412–0.987)n
1.00 1.019
(0.445–2.333)
Educational level Less than primary and primary Secondary University
1.00 2.038 1.772
(1.226–3.388)n (0.955–3.287)
1.00 0.885 0.996
(0.361–2.170) (0.372–2.669)
Intention to breast feed No Yes
1.00 3.530
(1.980–6.295)nnn
1.00 4.120
(1.457–11.649)nnn
(1.197–3.266)n
1.00 2.538
(1.051–6.132)n
Time to smoke first cigarette of the day before pregnancy Less than 30′ 1.00 More than 30′ 1.997 Reduction 50% or more No Yes Perception of risk Low High Advice received No Yes Willingness to get help Negative Positive
1.00 21.053
(12.111–36.596)nnn
1.00 33.477
1.00 2.200
(1.403–3.450)nn
1.00 15.340
(8.819–26.684)nnn
1.00 20.152
(8.733–46.504)nnn
1.00 6.689
(4.148–10.788)nnn
1.00 10.894
(4.753–24.972)nnn
1.00 0.996
(14.228–78.766)nnn
(0.439–2.259)
OR: odds ratio. CI 95%: 95% confidence interval. Adjusted data: for all significant variables in the binary logistic regression model except the variables ‘Cigarettes smoked daily before pregnancy’ and ‘Cigarettes smoked daily during pregnancy’. R2 de Nagelkerke: 0.739. n
p o 0.05. p o0.01. po 0.001.
nn
nnn
both variables are indicative of a higher level of nicotine dependence in the group that did not accept to participate. In contrast, other predictive factors found in our study can be modified by health-care staff and included in the smoking cessation interventions during pregnancy. Our results, like those from DiSantis et al. (2010), show that breast feeding has a protective effect on postpartum smoking. For that reason, it is important to combine both counselling topics (to breast feed and to stop smoking) earlier in the antenatal period. Therefore, it is necessary to systematically incorporate a recommendation to stop smoking in obstetric, antenatal and paediatric protocols, because some studies have shown that it is not made as routine (Winickoff et al., 2010), and this should be given as strongly as breast-feeding recommendations due to the benefits already known (McBride et al., 2003; Ripley-Moffitt et al., 2008). Almost half of the pregnant smokers (49.2%) were not given advice to stop smoking during pregnancy (Table 1), a higher percentage than reported by Park et al. (2009), and those who were given advice participated in a higher proportion in the postpartum smoking cessation intervention (OR: 20.152; IC 95%: 8.733–46.504) (Table 2). Thus, advice should be accompanied by specific information concerning the risk of SHS exposure because a third of the total sample (31,2%) had a low perception of this risk (Table 1). A further aspect that can be modified by health-care staff is to be proactive (always offering smoking cessation support to women at all maternal and child health visits) in order to take advantage of all cessation opportunities (Condliffe et al., 2005; Pollack et al., 2006; López et al., 2008). It is well known that this is
much more effective than being reactive (waiting for women to request help themselves and contacting the appropriate support staff to do so). Moreover, being proactive could be connected to the willingness to get help to stop smoking in women. In order to assess the reduction we established two categories (50% or more and less than 50%). The CO levels were measured in each woman and both groups had low CO levels, but with significant differences between them. This biomarker is reasonably specific for detecting heavy cigarette smoking but is of marginal use in detecting light smoking (SRNT Subcommittee on Biochemical Verification, 2002), which was the case of these women. These women are smokers of fewer cigarettes (7.9 cigarettes per day during pregnancy) (Table 1) and the cooximetry was obtained after delivery, when they had been hospitalised for a few days (24–72 hours) and therefore take days without smoking. Both factors contribute to obtain low levels of CO (similar to non-smokers); however, the aim to measure the CO was really to evaluate the difference between both groups, not to measure the smoking habit. To stop smoking is the safest action to minimise the risks of pregnancy and postpartum complications in both newborns and women. A reduction in tobacco consumption suggests that there may be a greater concern about health or also a greater willingness to get help than in case of women who do not have reduced. In fact, those who reduced their consumption by more than 50% accepted to participate in the cessation programme in a higher proportion. The advice given to pregnant and postpartum smokers must be to quit completely instead of reducing the consumption. However due to the effects in the health of newborn is dose
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dependent, some women may think that reducing the number of cigarettes is a healthier option. The percentage of participation in our study (62.9%) is close to that achieved in other studies involving similar interventions during post partum (Ruggiero et al., 2003; Hennrikus et al., 2010). In order to improve participation in these smoking cessation interventions it has been proposed the use of additional resources such as incentives, home visits, repeated telephone calls, email and postal contacts, among others (Lumley et al., 2009). Moreover, many of the studies which analysed the participation of pregnant women in smoking cessation interventions were focused on groups with specific sociocultural characteristics (ethnic minorities or low income women) (Curry et al., 2001; Giglia et al., 2007). This study is part of a RCT to evaluate the efficacy of a behavioural intervention in a population of pregnant women and the aim was to identify strategies that could be incorporated into the daily clinical practice without increasing human and economic resources in a general population of pregnant women. The study can be considered to have some limitations, such as the local sample population from only one hospital in a single country. However, the problem with smoking during pregnancy has been detected in other countries and is quite common (López et al., 2008; Diclemente et al., 2000; Park et al., 2009). Other limitation is the measurement of CO, because the CO level is not the best biomarker for the continuous active exposure during pregnancy in these smoking women, but it helps us to validate the self-declaration of the reduction and to discriminate between those who reduced more than 50% and those who did not (Pickett et al., 2005). Therefore in this study the aim to measure the CO level was to evaluate the reduction not the smoking habit. Another limitation could be the influence of memory bias when analysing what has happened during pregnancy retrospectively. Regarding the number of cigarettes smoked per day, as has already been documented women that smoke when pregnant feel guilty and, in some cases, under-report their consumption. However, we consider that there was no under-reported consumption interviewing women after having a healthy child. In conclusion, a significant number of smoker women still refuse to participate in smoking cessation programmes in the post partum. As recommendations for practice it is necessary to know that there are some aspects that could be modified by health professionals into the routine care, without increasing the resources, to improve the participation in these interventions. First of all, proactive smoking cessation programmes before, during and after pregnancy should be planned to all smoking women. In addition, the advice to quit smoking, together with information regarding the risks of SHS exposure, should be systematically included in routine mother/child health visits. This information must be given combined with the recommendation of breast feeding and with the same intensity. From the point of view of public health, the huge increase in the prevalence of smoking women poses the need to take advantage of the pregnancy as an opportunity for giving up smoking definitely. It would be necessary to identify what programmes of smoking cessation have better results in pregnant women and to know how to motivate health professionals to implement them. Conflict of interests The authors report no conflicts of interests. Acknowledgements This work was supported by the Ministry of Health and Consumer Affairs: “Evaluation of Healthcare Technologies” (PI 08/90705 IACS,
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Aragon Health Sciences Institute) and “Maternal, Child Health and Development Network” (RD08/0072). Spanish National Research Programme (2008–2011).
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