Mental Health and Smoking During Pregnancy

Mental Health and Smoking During Pregnancy Ellen J. Hahn, DNS, RN Professor University of Kentucky College of Nursing and College of Public Health Adult Smoking in England compared to Kentucky and the U.S., 2003 35 30 25 20 15 10 5 0 Total Men Women 26 23 33 28 25 24 21 35 31 England Kentucky U.S. From the Womb to the Tomb Significance   Only one-third of pregnant women who stop smoking during pregnancy remain smokefree one year after delivery. Infants born to women who smoke have a lower average birth weight. 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 Greatest Barriers to Smoking Cessation Among Pregnant Women      Low education level Smoking by the partner Smoking in the home and elsewhere in the mother’s environment Degree of nicotine addiction Lack of use of interventions known to promote cessation 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 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 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 is associated with depressive symptoms  Negative Thinking  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) 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 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) Measures       Smoking and quit history Fagerstrom Nicotine Dependence Scale Days exposed to secondhand smoke in home and car/truck CES-D Crandall’s Cognition Inventory (negative thinking) Everyday Stressors Inventory Treatment vs. Controls  Treatment and Control groups did not differ on:    Abstinence rate Urine cotinine Self-reported number of cigarettes smoked per day Abstinence Rates (N = 16) 40 35 30 25 Percent Treatment Control 20 15 10 5 0 Baseline Prenatal 1-3 wks Follow up PP 4-6 wks PP 2-3 mos PP Note: Intent-to-treat analysis used “What has been the MOST HELPFUL as you try not to smoke?”  Concern for the baby’s health    I just don’t want to smoke around her Thinking about my baby Better for my baby “What has been the MOST DIFFICULT as you try not to smoke?”  Others smoking   Going out around other people who smoke Seeing people smoke Husband goes outside to smoke  No urges (n = 3)  Nicotine Dependence 3.5 3 2.5 Percent Treatment Control 2 1.5 1 0.5 0 Baseline 1st Follow Up 2nd Follow Up Stage of Change: Percent Reporting Preparation, Action, or Maintenance 80 70 60 Percent Treatment Control 50 40 30 20 10 0 Baseline 1st Follow Up 2nd Follow Up Mean Days of Home Secondhand Smoke Exposure 8 7 6 Percent Treatment Control 5 4 3 2 1 0 Baseline 1st Follow Up 2nd Follow Up Mean Days of Car/Truck Secondhand Smoke Exposure 7 6 5 Percent Treatment Control 4 3 2 1 0 Baseline 1st Follow Up 2nd Follow Up Depressive Symptoms 35 30 25 Percent Treatment Control 20 15 10 5 0 Baseline 1st Follow Up 2nd Follow Up Negative Thinking 3.5 3 2.5 Percent Treatment Control 2 1.5 1 0.5 0 Baseline 1st Follow Up 2nd Follow Up Chronic Stress 35 30 25 Percent Treatment Control 20 15 10 5 0 Baseline 1st Follow Up 2nd Follow Up Follow up with Smoking Abstinent Mothers (n = 3)     Desired to protect their children from harm Viewed smoking cessation as a longterm/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 Limitations  Selection bias   Nonrandom assignment to group Treatment group more ready to quit at baseline   Small sample size Environmental influences not measured Marketing Tobacco to Women  Prominent Themes     Independence  “You’ve 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 Is there a Vaccine for Smoking? 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 Smoke-free Laws 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. “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 Public Health Benefits of Smoke-Free Laws     Nonsmokers protected Fewer children start to smoke Smokers consume fewer cigarettes More smokers quit Toxic Poisons in Secondhand Tobacco Smoke         Mercury Lead Arsenic Toluene Cadmium Ammonia Butane Ethanol Secondhand tobacco smoke contains more than 4,000 chemicals     5 regulated hazardous air pollutants 47 regulated hazardous wastes 60 known or suspected cancercausing agents More than 100 chemical poisons Toxic Poisons in Secondhand Tobacco 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 Air Pollution Dropped 91% After Lexington’s Smoke-free Law 250 PM 2.5 microgram per cubic meter 200 B EFORE 150 100 50 A FTER 0 After Lexington’s Smoke-free Law, Hair Nicotine Dropped by 56% 3 Median hair nicotine level 2.5 2 1.5 1 0.5 0 Pre-law 3 months Post-law The Average Decrease in Hair Nicotine Was Greater in Bar Workers 5 Geometric means for hair nicotine (ng/mg) 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 Pre-law Bar Restaurant 3-months post-law Figure 2. Geometric means by establishment type and time, adjusted for cigarettes per day Lexington’s Public Support and Knowledge of Health Risks Before and After the Law 100 80 60 56.7 40 20 0 Public Support SHS as Health Risk 70.2 64.0 74.7 Pre-law Post-law Public support for the law increased significantly Economic Impact of Lexington’s 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 nonalcohol serving establishments Nothing Kills Like Tobacco “By 2025, 21 years from now, 500 million people worldwide will die of tobacco-related disease…that is 9/11 every two hours for 21 years,” C. Everett Koop, March 2004 Building Collaborative Partnerships Contact Us!  University of Kentucky Tobacco Policy Research Program    www.mc.uky.edu/tobaccopolicy ejhahn00@email.uky.edu 859-257-2358 www.kcsp.uky.edu kcsp00@lsv.uky.edu  Kentucky Center for Smoke-free Policy  