Mental Health and Smoking During Pregnancy

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Mental Health and Smoking During Pregnancy

• Ellen J. Hahn, DNS, RN
• Professor
• University of Kentucky
• College of Nursing and
• College of Public Health

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Adult Smoking in England compared to Kentucky
and the U.S., 2003
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From the Womb to the Tomb
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Significance

• Only one-third of pregnant women who stop smoking
  during pregnancy remain smoke-free one year after
  delivery.
• Infants born to women who smoke have a lower
  average birth weight.

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Tobacco Use and Gender

• Women ascribe different meaning to smoking than
  men.
• Girls who perceive themselves as heavy are more
  likely to smoke than boys who think they are
  heavy.
• Women who quit gain more weight than their male
  counterparts.
• Single, low income mothers are more likely to
  smoke than married women of higher SES

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Greatest Barriers to Smoking Cessation Among
Pregnant Women

• Low education level
• Smoking by the partner
• Smoking in the home and elsewhere in the mothers
  environment
• Degree of nicotine addiction
• Lack of use of interventions known to promote
  cessation

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Background

• Health care policy and the use of clinical
  practice guidelines significantly increase
  smoking cessation rates among low income pregnant
  women
• Pregnant smokers should be offered extended or
  augmented psychosocial interventions that exceed
  minimal advice
• Little research on the maternal conditions that
  influence smoking during and after pregnancy

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Purpose

• To tailor a previously tested group intervention
  for depression to a population of pregnant
  smokers.
• To test the effect of a cognitive-behavioral
  group and telephone intervention during pregnancy
  and the postpartum period on
• Smoking abstinence rates
• Nicotine dependence
• Secondhand smoke exposure
• Depressive symptoms
• Negative thoughts
• Chronic stress

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Mental Health Issues in Pregnancy

• Depressive Symptoms
• Depressed pregnant smokers significantly less
  confident about quitting than the non-depressed
• Low depressive symptoms predictive of abstinence
  early in pregnancy
• Chronic Stress
• Pregnant smokers who report high levels of stress
  are less likely to quit smoking than those
  reporting low stress levels.
• Low stress predictive of abstinence early in
  pregnancy
• Negative Thinking
• Negative thinking is associated with depressive
  symptoms

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Methods

• Exploratory quasi-experimental, two-group design
• Intervention cognitive behavioral group/phone
  intervention during and immediately after
  pregnancy
• 4-session, 90-minute group
• Conducted at Housing Authority Office
• Treatment Group (n 11 pregnant smokers)
  Control Group (n 5 pregnant smokers) nonrandom
  assignment
• Recruited from WIC clinics (low income)

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Eligibility Criteria

• Pregnant, no more than 25 weeks gestation (1st or
  2nd trimester)
• 18 years of age or older
• Smoked any cigarettes (even just once in awhile)
  within the last 9 months
• Access to a telephone

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Data Collection Plan

• In-home interviews
• Baseline and 1-month post-group intervention
  (Prenatal)
• 2- and 6-months postpartum
• Telephone intervention calls (6) weekly with
  Treatment group
• Weekly abstinence rates early postpartum
• Open-ended in-home interviews at 6 months
  postpartum with abstinent participants in
  Treatment group (n 3)

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Measures

• Smoking and quit history
• Fagerstrom Nicotine Dependence Scale
• Days exposed to secondhand smoke in home and
  car/truck
• CES-D
• Crandalls Cognition Inventory (negative
  thinking)
• Everyday Stressors Inventory

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Treatment vs. Controls

• Treatment and Control groups did not differ on
• Abstinence rate
• Urine cotinine
• Self-reported number of cigarettes
  smoked per day

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Abstinence Rates (N 16)
Percent
Note Intent-to-treat analysis used
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What has been the MOST HELPFUL as you try not to
smoke?

• Concern for the babys health
• I just dont want to smoke around her
• Thinking about my baby
• Better for my baby

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What has been the MOST DIFFICULT as you try not
to smoke?

• Others smoking
• Going out around other people who smoke
• Seeing people smoke
• No urges (n 3)
• Husband goes outside to smoke

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Nicotine Dependence
Percent
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Stage of Change Percent Reporting Preparation,
Action, or Maintenance
Percent
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Mean Days of Home Secondhand Smoke Exposure
Percent
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Mean Days of Car/Truck Secondhand Smoke Exposure
Percent
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Depressive Symptoms
Percent
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Negative Thinking
Percent
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Chronic Stress
Percent
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Follow up with Smoking Abstinent Mothers (n 3)

• Desired to protect their children from harm
• Viewed smoking cessation as a long-term/life-long
  decision
• Desired a smoke-free environment for their
  children
• Shift in maternal thought processes
• All of the women viewed smoking as an unhealthy,
  nasty or disgusting habit

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Limitations

• Selection bias
• Nonrandom assignment to group
• Treatment group more ready to quit at baseline
• Small sample size
• Environmental influences not measured

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Marketing Tobacco to Women

• Prominent Themes
• Independence
• Youve Come a Long Way, Baby
• Find Your Voice
• Sexual Attractiveness
• Stress Relief
• Weight Control
• 40 of women think smoking controls weight

segment the female market on the basis of
current values, age, lifestyles.target young
adult female smokers American Tobacco Company,
1983
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Is there a Vaccine for Smoking?
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What Works to Help Smokers Quit?

• Price increases
• Smoke-free laws
• Mass media education
• Paid extended media campaigns
• Sporadic media interventions
• Cessation contests
• Health care delivery interventions
• Alternatives to school suspension

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Smoke-free Laws
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MOST People Are Exposed to Secondhand Smoke

• An estimated 3,000 lung cancer and 35,000 heart
  disease deaths occur annually among adult
  nonsmokers in the U.S. from exposure to
  secondhand smoke
• Approximately 60 of people in the U.S. have
  biological evidence of exposure.

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• I worked as a cocktail waitress in smoky
  restaurants and bars for 14 years. I have onset
  emphysema. My doctor says my constant exposure to
  tobacco smoke contributed significantly to my
  emphysema. No one should have to breathe tobacco
  smoke to hold a job. Suzanne H

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Public Health Benefits of Smoke-Free Laws

• Nonsmokers protected
• Fewer children start to smoke
• Smokers consume fewer cigarettes
• More smokers quit

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Toxic Poisons in SecondhandTobacco Smoke

• Secondhand tobacco smoke contains more than
  4,000 chemicals
• 5 regulated hazardous air pollutants
• 47 regulated hazardous wastes
• 60 known or suspected cancer-causing agents
• More than 100 chemical poisons

• Mercury
• Lead
• Arsenic
• Toluene
• Cadmium
• Ammonia
• Butane
• Ethanol

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Toxic Poisons in SecondhandTobacco Smoke

• Methanol
• Carbon Monoxide
• Hydrogen Cyanide
• Acetone
• Tar
• DDT
• Naphthalene
• Vinyl Chloride
• Formaldehyde
• Benzene

There is no safe level of exposure to firsthand
tobacco smoke or secondhand tobacco smoke
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Air Pollution Dropped 91 After Lexingtons
Smoke-free Law
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After Lexingtons Smoke-free Law, Hair Nicotine
Dropped by 56
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The Average Decrease in Hair Nicotine Was Greater
in Bar Workers
Geometric means for hair nicotine (ng/mg)
Figure 2. Geometric means by establishment type
and time, adjusted for cigarettes per day
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Lexingtons Public Support and Knowledgeof
Health Risks Before and After the Law
Public support for the law increased significantly
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Economic Impact of Lexingtons Law on Fayette
County Restaurants and Bars

• 3 increase in restaurant employment
• Bar employment remained stable
• No change in payroll withholding taxes in
  restaurants or bars
• No change in business openings or closures in
  alcohol-serving establishments or at non-alcohol
  serving establishments

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Nothing Kills Like Tobacco

• By 2025, 21 years from now, 500 million people
  worldwide will die of tobacco-related
  diseasethat is 9/11 every two hours for 21
  years,
• C. Everett Koop, March 2004

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Building Collaborative Partnerships
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Contact Us!

• University of Kentucky Tobacco Policy Research
  Program
• www.mc.uky.edu/tobaccopolicy
• ejhahn00_at_email.uky.edu
• 859-257-2358
• Kentucky Center for Smoke-free Policy
• www.kcsp.uky.edu
• kcsp00_at_lsv.uky.edu