Is advice to stop smoking from a midwife stressful for pregnant women who smoke? Data from a randomized controlled trial
Introduction
The aim of this paper is to examine whether midwives' advice and support to stop smoking is stressful for pregnant women. No randomized controlled trials have previously examined this issue, but it is important that such a question is addressed because there is evidence that such advice might be stressful. First, there is a strong association between social disadvantage, stress, and smoking. Smoking and, in particular, heavy dependence upon nicotine are preferentially concentrated in the poorest sectors of society [1], [2]. It is these women that are least likely to give up smoking spontaneously during pregnancy [3]. However, one of the commonest reasons given for continued smoking is the supposed stress-relieving properties of smoking [4]. As Oliver [4, p. 275] comments, “it seems irrational to try to take away a coping mechanism [by advising pregnant smokers to quit] and not look for any social and emotional consequences”. Second, there are important changes in behavior associated with smoking that appear unique to pregnant women as a group. Most women who do not stop smoking report cutting down for the health of the fetus [5]. Also, most smokers report accurately whether they smoke or not [6]. However, in pregnancy, up to a quarter of women who smoke deny it to their midwife [5]. Both these behaviors occur presumably because women feel negatively about their smoking and want to avoid adding to those negative feelings by receiving smoking cessation advice that would inevitably follow disclosure, or temper those negative feelings by reducing consumption. Third, there is some preliminary evidence that women who smoke find smoking cessation advice in pregnancy stressful. Forty-five percent of women who gave up smoking said that their midwives' advice on stopping and was not helpful, and 54% of women that continued to smoke perceived this as not helpful [7]. Sixty-eight percent of smokers and 27% of nonsmokers agreed that “these days pregnant women are under too much pressure to give up” and 79% of smokers and 51% of nonsmokers agreed that “there are things which are far worse for the unborn baby than smoking” [5]. A qualitative study of nonpregnant adults found that receiving advice to stop smoking from a health professional often aroused feelings of anger or guilt [8]. Fourth, during the conduct of this trial, we often found that midwives were nervous about delivering the more intensive arms of smoking cessation advice because they feared that it would damage their relationship with their patients.
Only one nonrandomized trial examined the influence of an intervention to assist pregnant women to stop smoking on women's stress [9]. In this study, midwives used a model fetus to show the increase in heartbeat following smoke inhalation. Women were then offered a small booklet with further information about the harm that maternal smoking does, and advice on how to quit. Women in the historical control group received usual care, which mostly consisted of a brief verbal caution that smoking was inadvisable, and, occasionally, the handing over of a general smoking cessation leaflet. There were no significant differences the odds of being a high scorer on the General Health Questionnaire at follow-up in late pregnancy or at 6 months postpartum. This is the only intervention study we know that has examined this issue.
Most commentators believe that it would be unethical for health care providers not to provide advice and support for women to stop smoking. Thus, trials are limited to examining whether more intensive advice and support is more stressful than standard care. This is the report of one such trial. In this randomized controlled trial, we tested a program based on the Transtheoretical Model (TTM) to assist smoking cessation in pregnancy. The trial compared a standard care intervention with two different and more intensive programs based on the TTM. So far, we have reported results concerned only with stopping smoking, confirmed by urinary cotinine measurement [10]. We found that there were small differences between the two TTM arms. Combining the two TTM arms, the OR [95% confidence intervals (CI)] for stopping smoking at 30 of gestation weeks was 2.09 (0.90–4.85) and at 10 days after delivery, the OR (95%CI) for quitting was 2.81 (1.11–7.13) for 10-week abstinence, respectively. The intervention appears to be as effective as other interventions reviewed in the Cochrane review of smoking cessation interventions in pregnancy, where the combined OR (95% CI) for quitting was 1.89 (1.67–2.13) [11]. We followed-up these women 18 months after delivery and asked them in retrospect about the self-help interventions they were given in pregnancy. Nearly all women in all arms remembered their interventions in pregnancy. Eleven percent of women in Arm A reported using their self-help intervention, 7% in Arm B and 17% in Arm C. Ten percent of women in Arm A reported that they found the intervention very or extremely helpful, compared to 3% of women in Arm B and 22% in Arm C. No women reported keeping the self-help intervention in Arm A, while 29% of women in Arm B and 39% in Arm C reported keeping the self-help materials. Thus, the intensity of the intervention was associated with different impacts on women in each of the arms, even if they did not stop smoking. We reported that the intervention was of doubtful pragmatic value considering its intensity because the absolute difference in long-term quit rates between the arms was very small. By recruiting only women who continued to smoke throughout pregnancy and excluding in-pregnancy quitters from the trial, we recruited women who were unable and possibly unwilling to stop unaided, which accounted for this small difference between the arms in the probability of quitting. In this report, we examine one of the secondary outcomes, stress induced in the mother as a potential consequence of intensive smoking cessation advice.
Section snippets
Participants
We recruited 16 of the 19 midwifery services in the West Midlands to participate in the trial. Midwives deliver antenatal care mainly in general (family) practices, rather than hospitals. Half of the available general practices were selected to participate, with one midwife declining. Midwives were asked to recruit all women aged 16 years and over who declared that they were still smoking at booking for maternity care (about 12 weeks of gestation). We estimate that they recruited 42% of
Results
At baseline, there was no significant difference by arm in the mean PSS scores. The means (SDs) were 1.6 (0.8) for all three trial arms for all women with baseline data. The means and SDs were also 1.6 (0.8) when the sample was confined to those with PSS change scores for the difference between booking and 30-week follow-up, and for only those with PSS change scores for the difference between booking and 10 days postnatal. Drop out from the cohort therefore appears to have been random with
Discussion
Women in Arms B and C of this study were subject to more frequent, more prolonged, and more intensive advice to stop smoking from their midwife as compared with women in Arm A. Women in the intensive advice arms were not more likely to feel stressed in late pregnancy or in the immediate postpartum period. There was also no evidence that women for whom pleasing their midwife by stopping smoking was important were more likely to feel stressed. There was no evidence that women that tried to stop
Acknowledgments
This trial was funded by the health authorities of the West Midlands. The interventions were developed by and are copyright of Pro-Change. Helen Evans and Sheila Hirst provided important support to the trial and we are grateful for their help.
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