Smoking during Pregnancy - Essay Example

Health Promotion Smoking During Pregnancy Background/History The impact of smoking on women is very hazardous. Women are susceptible to all of the diseases that men get from smoking and more. Women are susceptible to a number of diseases, tumors, and conditions that affect only women. Some studies show that women who smoke have twice as many illnesses related to smoking than men and they usually are identified between the ages of 35-44. [1] Smoking also causes many female productive problems including: placental abruption spontaneous abortion chromosomally normal fetus placenta previa bleeding during pregnancy premature rupture of the membranes stillbirths reaching menopause 1-2 years earlier Women who quit smoking are at about the same risk for these issues as the woman who does not smoke. [1] Smoking and using oral contraceptives can be very dangerous. It increases the risk of cardiovascular diseases and heart attacks. The use of tobacco and oral contraceptives often leads to stroke, venous thrombosis, and pulmonary embolism. There is also a growing awareness of the smoking that occurs during pregnancy. Smoking during pregnancy has been associated with growth retardation of the fetus, increased infant death rate and sudden infant death syndrome. Not only does smoking by-products pass through the placental barrier but they also are transmitted to the baby in breast milk. Breast milk production is also often decreased when mom smokes. Statistics show that mothers who smoke are less likely to breast feed. [1] Therefore both mothers and babies miss out on the importance of this process. Infants who have been exposed to tobacco have an increased risk of low birth weight and death at the time of birth. Low birth weight babies can also be very prone to a number of disorders including learning disabilities, diminished attention span, and increased risk of medical problems. [1] There are also a number of birth defects that are associated with smoking during pregnancy. Those include cleft lip/palate, clubfoot and limb defects. Children’s risks continue with increased childhood infection, bronchitis, negative impact on the overall respiratory health and lung development. It causes a reduction in pulmonary function and development which affects ability to exercise later in life. Last, the fact that mother smokes increases the risk that the child will be a smoker. [1] Haslam and Draper (2001) published a white paper on the need to stop smoking in pregnancy. The Secretaries of State for Health published in 1998 a paper that was reviewed by Haslam. The target set at that time was to reduce the amount of smokers during pregnancy by 15% by the year of 2010. At the time semi-structured interviews were held with pregnant women who smoke in one practice. There were 40 participants. The aim was to understand what motivates someone who is pregnant to smoke. The age range of the women in this study was from 15 to 35. The mean number of cigarettes that they smoked during the day was twelve. These women were asked what keeps them from quitting and four factors were most often noted. They felt it was difficult to quit because they would still be around other smokers, they had a lack of willpower, the physical and psychological addiction symptoms and they were more irritable when they smoked. They were then ask what actually prompts them to smoke and the answers were most often, stress, coping with their children, meals or tea and coffee breaks, boredom, socializing, seeing other people smoke, relationship problems and a it is a way to relax at the end of the day.[2]. Most of them had more than one prompt. There were some women in the group that had previous miscarriage and were afraid they might have another one and this was a prompter for them. The study more than anything else gave information on how the coping mechanism of smoking works. The study also showed that the women in the study were aware of the risks but this awareness was not enough to keep them from smoking. Many of the women had partners who smoked which made it that much more difficult Smoking cessation intervention with pregnant adolescents becomes even more important and in some ways more difficult. Albrecht, Caruthers, and Patrick et.al. (2006) studied this aspect of smoking and pregnancy. It was noted that the smoking rate among pregnant teens is 59-62% and 60-80% of these adolescents will continue to smoke during the whole pregnancy. [3]. This study was to determine what the short and long term effect of a cessation program specifically for adolescents might be able to do as fare as being effective. The used a randomized control trial that had follow up at 8 weeks, and 1 year. The study includes 142 pregnant teenage women who were 14-19 years old. Even with intervention, however, there was no difference in the numbers of girls who quit and those that did not. They will look at this again in an effort to make a difference as the negative maternal and child effects of smoking at this young age can be devastating including fetal growth, development, and survival. Smoking Cessation and Relapse during Pregnancy Cessation of smoking during pregnancy is of utmost importance however, it is even more important to convert that abstinence to long term cessation. This will protect the mother in the long term from greater chances of heart disease and cancer [4]. At the same time, it protects the child from exposure to tobacco smoke while still developing. [5] Those women who give up smoking are more likely to be able to convince a spouse to quit smoking. On the average, 25-40% of women who are pregnant give up smoking prior to their first prenatal visit. Research indicates that even minimal intervention at this stage can increase the numbers of women who quit. The problem is that 60-80% of these women return to smoking within 6 months of postpartum and 80-90% relapses by one year. Unfortunately, even with increased amounts of public awareness, smoking among young adult pregnant women continues to be a problem. According to a study done by Abrevaya (2007), [6] young women who quit smoking during their first pregnancy are often smoking again in their second pregnancy and 10% of women who were non smokers during their first pregnancy were smokers during their second pregnancy. This, according to Abrevaya (2007) indicates a trend of young women not understanding the problems related to smoking or not able to maintain non-smoking status [6]. Both of these issues show a need for a public health initiative related to stopping smoking during pregnancy and maintaining that status. Hannover, Thyrian, and Ebner (2008), further studied the issue showing in agreement that women who quit smoking during pregnancy usually return to smoking within 12 months. [7] They studied over 500 women and discovered that 69% did not intend to quit smoking in the next 6 months and for those that had quit during pregnancy, 80% did not want to resume smoking within the next 6 months or until after weaning. The conclusion of this study was that there is a need to increase efforts to reduce smoking during pregnancy and postpartum as well as give better supporting techniques to those that do quit. Predictors of spontaneous quitting, which is defined as abstaining immediately after learning of pregnancy, among pregnant women have been well studied and documented. These include early entry into prenatal care, first pregnancy, and being of white race or ethnicity. This, however, occurs in less than 30% of pregnancies though it has the greatest reduction in risk factors. The other 70% who smoked prior to pregnancy will smoke at least one cigarette after their pregnancy is discovered and usually will continue at the same or slightly less number that they smoked prior to pregnancy. [8] Gravity may have a lot to do as to whether a woman quits or does not quit during pregnancy. Morris, Maconochie, and Doyle (2007) studied the problem of whether or not gravity played a part in this issue. A large UK sample of women were studied in an effort to do a cross-sectional survey of women over a twenty year time period. The objective was to understand whether women who were in the second and third pregnancy were more likely to relapse in smoking during the pregnancy. 19% of the women studied smoked during the first trimester of their pregnancy. The study did happily show that there was a decrease in smoking prevalence over at 20 year period. The evidence from this study did show that the woman who was multigravida was more likely to smoke throughout her pregnancy than the primagravida. [9] This trend rose as the number of pregnancies rose and many of these women had no change in consumption from prior to pregnancy. These women also did not smoking when the baby comes home. The end result of this study and other studies like it showed that younger women were more likely to be smokers when they got pregnant and multigravida women make up the majority of pregnant women. These women are more likely to smoke during the whole pregnancy and much more likely to continue to smoke as if there were no reason to change. Studies also show that women who smoke as multigravidas also have a tendency to report smoking fare fewer cigarettes than they are smoking. This is tested by cotinine levels during testing. Recommendations for Pharmacological Smoking Cessation during Pregnancy It has been shown, which has been noted in this paper that smoking cessation during pregnancy has not been very effective and those programs that have been effective still have a large relapse rate. Nicotine replacement therapy, bupropion and varenicline are all effective pharmacological smoking cessation strategies in the nonpregnant population. However, whenever drug treatments are considered during a pregnancy, the developing fetus must be considered first. The prediction of the effects of drugs on the fetus is not always accurate and may be very difficult to surmise. The affects on mum may be immediate but the effects on the baby may not be noted until some time later. A healthy balance of risk and benefits must be weighed and the potential benefit must outweigh the risk. Unfortunately at this time there is not a lot of information available as to what the risks may be of using these types of drugs. There are studies being conducted but the results are not in yet. Other Health Promotions There are many smoking initiatives for pregnant women available throughout the world; however the previously discussed statistics show to a great extent they do not work and need to be rethought. There has recently been a new campaign begin in England which has already had many referrals, that campaign involves 10 supportive components demonstrating efforts to help quit smoking. [9] The new initiative is called Stop Smoking Interventions in Primary Care. At this time, it is showing promise. A Nurse Practitioner was assigned to this program because women have a tendency to talk with another woman during pregnancy. The service aims to reach pregnant women and their families in their own surroundings, concentrating on areas specific areas when it is noted that there is a high incidence of low birth weight babies. Women are referred to the program by midwives, consultants, medical staff, GPs, health visitors and pharmacies. They are also able to make appointments through specialty midwives. Another initiative taking place by the Department of Health in Yorkshire and Humber is under a lot of controversy. In this program, called the Significant Others Supporters, persuades pregnant women from stopping smoking by paying them with shopping vouchers. These women must pass urine screening when claiming the vouchers. Some feel this bribery and some think what ever works. It is still being evaluated for effectiveness. [10] The belief here is that it is important enough to have them not smoke that the cost upfront does not come anywhere near the costs that occur as a result of the smoking. Regional Director of Public Health NHS Yorkshire and Humber says, “Protecting unborn babies is worth every penny. Many women manage to stop smoking as soon as they find out they are pregnant but many cannot. There is strong evidence that giving a small additional incentive can help.”[10] The expectant mum is given a voucher at the four week quit date and then monthly during her pregnancy as well as for two months beyond the baby’s birth to encourage her to continue. They are required to blow into a carbon dioxide monitor once a month to prove they have actually not smoked. The March of Dimes campaign is an important initiative which provides much information on the national and worldwide scale but when brought down to the local level, is not always significant. They do provide The American Legacy Foundation which has support available by internet and on the phone twenty four seven. They also provide education for healthcare workers who are trying to educate women who are pregnant. [11] Overview of Initiative Ewles and Simnett (2003) presented a planning model to help in the designing of a health initiative. [12] That model will be used here as a seven step process. This planning model includes, identifying resources, planning evaluation methods, setting an action plan, and action. This model sets priorities based on identified needs, potential strategies to address those needs, and evaluation methods to assure that the action was effective. Each of thee planning pieces provides part of the complete promotion creating the initiative. (McClure, 2010). [13] Each of those parts will be used here to complete this initiative. The health promotion needs here are educational in nature. The target population is women who are pregnant and smokers. There is also a great need for continued support throughout the pregnancy, helping these women continue not to smoke. The goal would be to promote a healthy lifestyle for the mother and baby and prevent the complications from smoking. A true understanding of the methods needed to help these women and quit and stay quit as well as the research related to alternatives that might be used while pregnant. The assessment will need to include the strengths of the communities in putting together programs that work. [14] It must be remembered that it is easy to design an initiative using negative ideas instead of positive. In other words the initiative should be designed with the idea of ‘securing a healthy lifestyle for pregnancy mothers and babies”, instead of “reducing the number of smoking mothers”. All initiatives should be about health and not illness. Aims and objectives are very important in any planning but certainly in the planning of an initiative which can be quite complicated and involve many people and resources. [15] Part of the aims and objectives is to assure that data gathering is accurate Goals should be set here. The desired achievement of the program is also set. In this case the aim would be “All women will maintain a healthy lifestyle during pregnancy and during child rearing which includes cessation of tobacco.” [15] This is where it is important to see health as more than the absence of disease. The role of theory plays an important role here as the determinants of health are examined and needs are assessed and focused on positive directions and capacities instead of just negative. For example, as we look at the tabled below: designing our initiative can be done under a negative approach or a positive approach. Our initial inclination is always to design under a negative approach because it is in the realm of how we have been thinking about health, which is the absence of disease [16] However, we want to move our thoughts to the positive approach which is the presence of health. Level of Change Needed Negative approach to design Positive approach to design Individual Risk Factors Resilience and personal strength Organizational Gaps in service; lack of resources; service system dysfunction Services: Resources; Opportunities for partnerships and collaboration Community Risk Factors Community Assets Society Threats Opportunities (Chinn 2000). This chart implicates the negative and positive approach to the design of an initiative as previously discussed in the narrative. Relative Theory and Evidence Evidence is important in designing any initiative. It is noted that there is much evidence, some that is convincing and some that is not, based on the studies and their finding. As an initiative is designed, one must determine which evidence to keep and which to eliminate and why. It has been noted in the previously discussed studies that the types of interventions that seem to work the bet are that include at least one monthly visit, monthly telephone contact, and weekly mailed materials for homework. The interventions that were second in how well they did were ones that used brief counseling by a health educator and eight self help books mailed weekly. The interventions with the lowest quit rate were those that utilize a videotape, pamphlet, and brief interaction with the health educator. [9, 10, 11]. In designing an initiative one must remember to review the prior research which has been done here. There are many controversies in the research as to what works but as noted above there are things that should be considered as part of any initiative. These will need to be included in the initiative that is designed here. Those things will include the need to support this woman throughout here pregnancy. Teaching her why she should quite smoking and even how to quite smoking and then to abandon her is a guarantee that she will begin to smoke again, either right away or as soon as a stressor encourages her to. This support must be almost continuous in some way. For example the most successful program studied sent home study booklets with testing to help keep the ideas in their minds all of the time. Educational Approach and Outline of Promotion Needs The aims of this initiative will need to be achieved through the educational approach. The education approach was determined because of the great need of education for so many people. [17] It gives the structure needed to provide this education for large numbers of people. The women who smoke and are pregnant or recently delivered need support through this initiative to not only quit but to prevent them from starting again as soon as the baby is born. Local primary care practitioners, pediatricians and obstetrics physicians as well as midwives and nurse practitioners will need this information and be part of this initiative. The community will need education as will the spouses and other relatives involved. [18] When developing continuing strategies to reach an aim, it is best to involve several different groups that are familiar with the population of women and babies at risk. It is important to have many people as possible involved with various pieces of the design of the promotion. A multidisciplinary committee meeting helps to do this with pre-assigned assignments allowing a strong start from the beginning. [19] Resources Resources must include much more than the money needed to make the initiative happen. In this case there will be a lot of dedicated time by both healthcare personnel and volunteers. In the brainstorming session back in the committee groups, this should be part of the brainstorm. What else could possibly be needed to get this promotion off the ground? There will be a need for a place to hold meetings and the staff to do the teaching as well as any teaching materials. There will be a need for measuring outcomes and what kind of data equipment and supplies are needed for this? There will be a need to distribute materials as well as print them Evaluations will need to be done to determine whether outcomes are achieved. This needs to be determined before the kick of for the promotion so that there will be consistency in measuring the data. Data collection methods must also be determined ahead of time and everyone instructed on how to use them. There, then, must be a plan of action to determine how all of this work is going to get done to achieve the initiative at hand. There are many ways to achieve an outcome analysis. It would be a good decision in this case to have a participant analysis which examines the effect the initiative had on the people it is meant to help. Early in the initiative, it might be determined if there are several women who can be specifically followed and data collected on. These need to be random choices so data is not skewed. A list of questions would be presented regularly to the group that is being tracked. Those questions might look like this: 1. Has the program helped you quit smoking? 2. Do you have a great urge to smoke? 3. What are some of the things that can be done to better support you? 4. Have you quit smoking? 5. Do you plan to remain a non-smoker? Initiative Review Needs and Priorities Education for quit smoking and support such as medications, diet, and exercise. Availability of support mechanisms for women when needed Aims and Objective Women who are pregnant and breast feeding or raising children will lead healthy lives that are smoke free. Achieve Aims Education of primary providers Education of Nurse Midwives and NP’s Education of Women who are childbearing age Education of Women who are pregnant and breastfeeding Education of spouses and families Resources Educators, Nurses, Healthcare groups, Time, budget, printing supplies, areas for education as well as activity area. Recent studies available. Evaluation Outcome evaluation will need to use statistical data as part of the evaluation. Are there healthier mothers and children with fewer co-morbitites? Training in data collection to assure that everyone is doing it the same way. Regular collection and analysis of data. Outline for Plan of Action Action Plan Week 1 Core group meets, bring with them research in their areal. Core group includes nutrition, pulmonary, nurse midwives, medical, community member Week 2 Brainstorming with core group Week 3 Review Aims and goals as well as how they will be measured. Week 4 Design education materials to be used and consign them for printing Week 5 Distribute materials to all of those that will need them during the initiative. Begin preliminary training of those that will be participating in conducting the initiative Week 6 Assure all resources are prepared and available. Come up with contingency plans Week 7 Kick off initiative. Big splash. Assure good new coverage and fun activities. Week 8 Begin evaluation and re-planning Conclusion In conclusion, health promotion is about wellness and not illness. Designing an initiative is about providing the knowledge and resources that are needed to allow a population to choose the right things to promote a healthier happier lifestyle. In this case there are some other initiatives already in place but statistics show that they are not helping decrease the numbers of women who are pregnant and smoking so another way must be found. This means the development of programs that are readily available in close proximity for use for this population. There is also a great need to assure that all the right people are at the table when the design is made including government officials, physicians, teachers, public health nurses, parents and more. This paper dealt with an initiative to help women who are smoking and pregnant, stop and maintain the non-smoking status by picking a healthy lifestyle instead on dwelling only on the smoking. The planning process is done using the Ewles and Simnett model for health promotion. Resources 1. Lawrence, P., Aveyard P., Evans O., et.al. A cluster randomized controlled trial of smoking cessation in pregnant women comparing interventions based on the transthcorctical model to standard care. Tobacco Control. 2003. 12: 168-177. 2. Haslam, C., & Draper, E. A qualitative study of smoking during pregnancy. Psychology, Health & Medicine, 2001. 6 (1) 3. Albrecht, S., Caruthers, D., Patrick, T. A randomized controlled trial of a smoking cessation intervention for pregnant adolescents. 55(6). 402-410. 4. Tutka P., Wielosz M., Zatoriski W. Exposure to environmental tobacco smoke and children health. International Journal of Occupational Medicine and Environmental Health. 2003:15(4): 1007-15. 5. Polanska, K., Wojciech H., & Sobala, W. Smoking relapse one year after delivery among women who quit smoking during pregnancy. International Journal of Occupational Medicine and Environmental Health. 2005: 18(2) 159-165. 6. Abrevaya, J. Trends and determinants of second-pregnancy smoking among young-adult mothers who smoked during their first pregnancy. Nicotine and Tobacco Research 10(6). 951-957. 7. Hannover, W., Thyrian, J., Ebner, A. et.al. Smoking during pregnancy and postpartum: smoking rtes and intention to quit smoking or resume after pregnancy. Journal of Women’s Health. 2008: 17(4). 8. Castrucci, B., Culhane, J., Chung, E. Smoking in pregnancy: patient and provider risk reduction behavior. Journal of Public Health Management Practice. 2006. 12(1). 68-76. 9. Staines, R. New stop smoking initiative to be launched in England. Nursing times.net. 2009: 10. Dunwell, C. Should pregnant women be paid to stop smoking? Available at http://www.mirror.co.uk/life=style/real-life/2009/07/23/should-pregnant-women-be-paid-to 11. Improvement and Development Agency. Helping women to stop smoking in SheffieldPublished: 2008. available at http://www.idea.gov.uk.idk/core/pageId=8944462&aspect=full 12. Ewles L., Simnett I. Promoting Health a Practical Guide Baillere Tindall: Elsevier. 2003. 13. McClure, J. Use of Ewles and Simnett for health promotion. Adolescence. 1998: 33. 565-574. 14. Webb, D., Boyd NR, Messina, D The discrepancy between self-reported smoking status and urine continine levels among women enrolled in prenatal care at four publicly funded clinical sites. Journal Public Health Management Practice. 2003: 9(4). 322-325. 15. Secker-Walker FH, Dana GS, Solomon LJ, et.al. The role of health professionals in a community-based program to help women quit smoking. Prev Med 2000: 30(2) 126-137. 16. Chung EK, McCollum KF, Elo IT, et. al. Maternal depressive symptoms and infant health practices among low-income women. Pediatrics. 2004. 113(6). 523-529. 17. McFarlane J., Parker B., Soeken K. Physical abuse, smoking, and substance use during pregnancy; prevalence, interrelationships, and effects on birth weight. Journal Obstetric Gynecology Neonatal Nursing: 1996: 25(4). 313-320. 18. Kellow, J. Pregnancy and nutrition. 2010. available at: http://dietitianresources.co.uk 19. Hajek P., West R., See A. Randomized controlled trial of a midwife delivered brief intervention in pregnancy. Addiction. 2001: 96. 485-494. 20. Relph, D. BBC News Women and smoking, high risk babies in UK Health. 2010. available at http://www.bbc.womenandsmoking Read More