l
HealthBriefs A Smoking Cessation Program for Pregnant Women: An Exploratory Study BRIAN G. DANAHER, PHD, CATHERINE M. SHISSLAK, PHD, CAMILLA B. THOMPSON, MA, AND JULIAN D. FORD, PHD
It is generally acknowledged that cigarette smoking is this country's foremost preventable cause of death and disability.1 2 Public health campaigns have alerted the public about the dangers of smoking and the reduction of risk attendant upon its cessation.3'4 In contrast to vigorous campaigns waged in other countries, however, this country has shown surprisingly little attention to the special subgroup of pregnant women smokers who stand at unique risk. There is growing evidence that smoking in pregnancy significantly increases the incidence of stillbirth and spontaneous abortion.1' 25 It has been estimated that in 1968 smoking accounted for more than 4,600 perinatal deaths.2 There is also some evidence that the excess risk of perinatal mortality can be eliminated if cessation is achieved within the first trimester.6 Finally, parental smoking has been related to infant sudden death syndrome7 and childhood respiratory problems.8 Pregnancy may be an optimal time for smoking cessation programs since it is a key period of dual responsibility (mother and infant health). Cessation programs for pregnant women smokers have received initial research attention in Great Britain. Interventions have typically involved brief, focused discussion with physicians relating the evidence on special risks and methods for achieving abstinence. Outcome results were negligible for one such program reported in the literature.9 In a larger controlled trial, however, it was Address reprint requests to Dr. Brian G. Danaher, Stanford Heart Disease Prevention Program, Department of Medicine (Room S-005), Stanford University Medical Center, Stanford, CA 94305. Dr. Shisslak is currently Director of Family Services, VA Hospital, Albuquerque, NM; C. Thompson is research assistant in the Stanford Heart Disease Prevention Program; Dr. Ford is Assistant Professor of Psychology, University of Delaware, Newark. This paper, submitted to the Journal November 14, 1977, was revised and accepted for publication March 13, 1978.
896
found that 14 per cent of women assigned to the intervention group were abstinent at an 11-week follow-up compared to only 4 per cent in the usual care control group.10 Admonishments delivered by physicians can be powerful treatment tools for smoking control, particularly at times of illness related to smoking.11 The aforementioned evidence suggests, however, that more intensive programs emphasizing skills-training might be needed for this special group of pregnant women smokers. This report describes an exploratory study of a program combining risk information and strategies for cessation drawn from the literature on behavioral approaches to smoking control.12' 13
Method Participants Eleven pregnant women (four primigravida) volunteered. A fee of $15 and a refundable $15 attendance deposit were collected. Participants averaged 17.6 weeks into pregnancy and 12.5 years smoking. Eight women had made at least one previous attempt to quit smoking; the median period of prior self-imposed abstinence was three months (range: 2-24 months). All but two women had completed college or trade/business school. Procedure
Participants met in a group of six, 2-hour sessions over seven weeks. Meetings were directed by three consultants (two PhD clinical psychologists and one MA counselor). Each participant received a document outlining the risks of smoking during and following pregnancy.* Skills-training procedures were presented in three sequential phases. The *Available on request to authors. AJPH September, 1978, Vol. 68, No. 9
PUBLIC HEALTH BRIEFS TABLE 1 Demographic and Outcome Measures in Smoking Cessation Program for Pregnant Women Average Smoking Rate (number/day) Participant Number
01 02 03* 04 05 06* 07 08 09t 10 11
Age§
Weeks of Pregnancy§
Onset of Pregnancy
Week 1 of Program
27 28 29 27 31 27 29 29
24 18 15 15 26 18 13 19
25 30 30 25 25 30 15 20
16 18 26
Week 7 of Program (5-17-77)
9-month Follow-up (2-22-78)
Delivery Date
3 5 25 2 0 8 0 0
20 13 20 20 0.5 20 0 0
7-25-77 9-17-77 8-29-77 9-26-77 6-30-77 8-17-77 10-11-77 8-12-77
14
20
N.A.
0 20
17 0
9-16-77 8-29-77
14 17
12
35
9
30
11 34 14
37 25
18 19
35 20
27 20
§Determined at week 1 of the program
*Participant dropped out of program prematurely. tParticipant had a miscarriage and made no active effort to quit smoking while attending the final two meetings.
preparation phase (week 1) included instruction in self-monitoring (cigarettes and smoking urges) and deep muscular relaxation. The quitting phase (weeks 2-3) emphasized use of regular-paced aversive smoking with a concurrent break with usual smoking. The final maintenance phase (weeks 47) provided instruction in methods for coping with and eventually eliminating lingering smoking urges. Audiotapes were used to direct home practice of relaxation and aversive smoking. A printed manual outlined the treatment regimen and served as a permanent reference.*
Results Despite the attendance deposit, group membership diminished over the course of the program. Two women dropped out unexpectedly, one (#6) after attending two meetings and the other (#3) following the fourth meeting. A third participant (#9) experienced a miscarriage at week 3 and continued in attendance while making no further attempt to quit smoking. Data on all participants are summarized in Table 1. Daily smoking was evaluated at onset of pregnancy (via retrospective report), the first and final weeks of the program, and at a 9-month follow-up. Nine of the 11 women reported reduced smoking once they became pregnant. Further smoking reductions were observed during the course of the program for all but three participants. Individual smoking histories for the period following program termination can be considered with respect to two central criteria: 1) abstinence during the remaining period of pregnancy, and 2) abstinence following the delivery date. Of the eight women who attended the complete program and who were pregnant
at termination, three (#5, 7, 10) were abstinent and two (#8, 11) dramatically reduced daily smoking for the remainder of the pregnancy period. Delivery date was a noteworthy time of change for two women with one (# 10) resuming smoking and another (#11) achieving complete and lasting abstinence at that time. One woman (#8) stopped smoking two months after the birth of her child. It is interesting to note that, with the obvious exception of the woman who experienced the miscarriage, all participants gave birth to healthy infants. At the 9-month follow-up assessment, three women were found to be abstinent (#7, 8, 11) and one woman (#5) was smoking less than one cigarette daily. Relatively minor changes were observed in the smoking histories of the remaining participants. Limited sample size precludes identification of significant prognostic indicators, but several interesting associations emerged. Prior experience with birth complications was clearly related to successful performance. A correspondence was also obtained between smoking reduction and diminished consumption of alcoholic beverages during pregnancy.
Discussion
*Available on request to authors.
The present results provide tentative support for the hypothesis that an intensive program of risk education and behavioral skills-training can assist pregnant women to stop smoking. The absolute level of abstinence achieved-both during the remaining period of pregnancy and postpartumranks well above other results reported in the literature. The data further suggest that risk had been substantially reduced for some participants. Optimism must be tempered, however, by several key points: 1) the small sample size, 2) omission of a no-contact
AJPH September, 1978, Vol. 68, No. 9
897
PUBLIC HEALTH BRIEFS
control condition that would measure "spontaneous" quitting, 3) omission of an attention-placebo control condition that would assess the effects of support and encouragement, and 4) the fact that participants were volunteers relatively well advanced in pregnancy. Controlled research is required to develop empiricallytested programs aimed at this special group of smokers. Measurement should focus on recruitment issues in addition to achieving abstinence during pregnancy (when acute risks can be eliminated) and postpartum. In addition to serving immediate public health needs, specially-tailored, effective smoking cessation programs could be used in experimental epidemiologic research to more clearly establish the parameters of risk. Finally, expanded research and program development would directly contribute to a community-wide approach to smoking control.
REFERENCES 1. Larson PS, and Silvette H: Tobacco: Experimental and Clinical Studies (supplement III). Baltimore: Williams & Wilkins, 1975. 2. U.S. Department of Health, Education, and Welfare, Public Health Service. The Health Consequences of Smoking. Atlanta: Center for Disease Control, 1973 and 1976. DHEW Publication Nos. (HSM) 73-8704 and (CDC) 76-8704. 3. Public puffs on after ten years of warnings. Gallup Opinion Index, No. 108:20-21, 1974. 4. U.S. Department of Health, Education, and Welfare, Public Health Service. Adult Use of Tobacco, 1975. Atlanta: Center for Disease Control, 1976.
5. Fielding JE: Smoking and pregnancy. N Engi J Med, 298:337339, 1978. 6. Butler NR, Goldstein H, and Ross EM: Cigarette smoking in pregnancy: Its influence on birth weight and perinatal mortality. B Med J, 2:127-130, 1972. 7. Bergman AB, and Wiesner LA: Relationship of passive cigarette-smoking to sudden infant death syndrome. Pediatrics, 58:665-668, 1976. 8. Colley JRT, Holland WW, and Corkhill RT: Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. Lancet, 2:1031-1034, 1974. 9. Donovan JW: Randomized controlled trial of anti-smoking advice in pregnancy. Br J Prev Soc Med, 31:6-12, 1977. 10. Baric L, MacArthur C, and Sherwood M: A study of health education aspects of smoking in pregnancy. Int J Health Ed, 19: 116 (supplement), 1976. 11. Lichtenstein E, and Danaher BG: Role of the physician in smoking cessation. In Brashear RE, and Rhodes ML (eds.), Chronic Obstructive Lung Disease, St. Louis: Mosby, in press, 1978. 12. Danaher BG: Rapid smoking and self-control in the modification of smoking behavior. J Consult Clin Psychol, 45:1068-1075, 1977. 13. Danaher BG, and Lichtenstein E: Become an Ex-smoker. Englewood Cliffs, New Jersey: Prentice-Hall, in press, 1978.
ACKNOWLEDGMENTS Thanks are extended to W. L. Heinrichs, MD, and R. W. Jeffery, PhD, for their careful reading of earlier drafts of this article. Supported in part by National Institutes of Health Research Service Award (#5 T32 HL 07034-03) from the National Heart, Lung and Blood Institute.
Social Characteristics of Natural Childbirth Users and Nonusers CAROLYN CAVE, PHD, RRA
Introduction Because a significant number of American women apparently want a conscious participation in childbirth,1 psychophysical preparation has become an integral part of childbirth care today. However, some prepared childbirth modes, especially the Read and Lamaze Methods, have continued to cause controversy in American obstetrics, often because these methods are vastly different from maternity care routinely practiced in American hospitals and cited by critics as mechanized,2 dehumanizing,3 or too scientific.4 One might Address reprint requests Dr. Carolyn Cave, Associate Professor and Chairperson, Department of Medical Records Administration, School of Allied Health Professions, Ithaca College, Ithaca, NY 14850. This paper, submitted to the Journal April 4, 1977, was revised and accepted for publication January 24, 1978. 898
say, then, that couples who use natural childbirth in the United States are innovators in the sense that this is an idea perceived as "new" by the patient with newness being in the eyes of the individual.5'6 Findings from previous natural childbirth studies have suggested that social, cultural, and motivational elements need to be identified among natural childbirth users.7 Some have concluded that success with natural childbirth lies in defining the "type of person" rather than merely measuring medical and psychological indicators.8 In light of this, we aimed to define a sociological profile of a natural childbirth user compared with a nonuser of this innovation; findings are compared with other innovation research that explains the "type of person" most likely to adopt a new idea. Compared with later adopters, early adopters have more years of education, are more cosmopolitan, have more knowledge about their disease or illness, are younger, and have a higher inAJPH September, 1978, Vol. 68, No. 9
HealthBriefs A Smoking Cessation Program for Pregnant Women: An Exploratory Study BRIAN G. DANAHER, PHD, CATHERINE M. SHISSLAK, PHD, CAMILLA B. THOMPSON, MA, AND JULIAN D. FORD, PHD
It is generally acknowledged that cigarette smoking is this country's foremost preventable cause of death and disability.1 2 Public health campaigns have alerted the public about the dangers of smoking and the reduction of risk attendant upon its cessation.3'4 In contrast to vigorous campaigns waged in other countries, however, this country has shown surprisingly little attention to the special subgroup of pregnant women smokers who stand at unique risk. There is growing evidence that smoking in pregnancy significantly increases the incidence of stillbirth and spontaneous abortion.1' 25 It has been estimated that in 1968 smoking accounted for more than 4,600 perinatal deaths.2 There is also some evidence that the excess risk of perinatal mortality can be eliminated if cessation is achieved within the first trimester.6 Finally, parental smoking has been related to infant sudden death syndrome7 and childhood respiratory problems.8 Pregnancy may be an optimal time for smoking cessation programs since it is a key period of dual responsibility (mother and infant health). Cessation programs for pregnant women smokers have received initial research attention in Great Britain. Interventions have typically involved brief, focused discussion with physicians relating the evidence on special risks and methods for achieving abstinence. Outcome results were negligible for one such program reported in the literature.9 In a larger controlled trial, however, it was Address reprint requests to Dr. Brian G. Danaher, Stanford Heart Disease Prevention Program, Department of Medicine (Room S-005), Stanford University Medical Center, Stanford, CA 94305. Dr. Shisslak is currently Director of Family Services, VA Hospital, Albuquerque, NM; C. Thompson is research assistant in the Stanford Heart Disease Prevention Program; Dr. Ford is Assistant Professor of Psychology, University of Delaware, Newark. This paper, submitted to the Journal November 14, 1977, was revised and accepted for publication March 13, 1978.
896
found that 14 per cent of women assigned to the intervention group were abstinent at an 11-week follow-up compared to only 4 per cent in the usual care control group.10 Admonishments delivered by physicians can be powerful treatment tools for smoking control, particularly at times of illness related to smoking.11 The aforementioned evidence suggests, however, that more intensive programs emphasizing skills-training might be needed for this special group of pregnant women smokers. This report describes an exploratory study of a program combining risk information and strategies for cessation drawn from the literature on behavioral approaches to smoking control.12' 13
Method Participants Eleven pregnant women (four primigravida) volunteered. A fee of $15 and a refundable $15 attendance deposit were collected. Participants averaged 17.6 weeks into pregnancy and 12.5 years smoking. Eight women had made at least one previous attempt to quit smoking; the median period of prior self-imposed abstinence was three months (range: 2-24 months). All but two women had completed college or trade/business school. Procedure
Participants met in a group of six, 2-hour sessions over seven weeks. Meetings were directed by three consultants (two PhD clinical psychologists and one MA counselor). Each participant received a document outlining the risks of smoking during and following pregnancy.* Skills-training procedures were presented in three sequential phases. The *Available on request to authors. AJPH September, 1978, Vol. 68, No. 9
PUBLIC HEALTH BRIEFS TABLE 1 Demographic and Outcome Measures in Smoking Cessation Program for Pregnant Women Average Smoking Rate (number/day) Participant Number
01 02 03* 04 05 06* 07 08 09t 10 11
Age§
Weeks of Pregnancy§
Onset of Pregnancy
Week 1 of Program
27 28 29 27 31 27 29 29
24 18 15 15 26 18 13 19
25 30 30 25 25 30 15 20
16 18 26
Week 7 of Program (5-17-77)
9-month Follow-up (2-22-78)
Delivery Date
3 5 25 2 0 8 0 0
20 13 20 20 0.5 20 0 0
7-25-77 9-17-77 8-29-77 9-26-77 6-30-77 8-17-77 10-11-77 8-12-77
14
20
N.A.
0 20
17 0
9-16-77 8-29-77
14 17
12
35
9
30
11 34 14
37 25
18 19
35 20
27 20
§Determined at week 1 of the program
*Participant dropped out of program prematurely. tParticipant had a miscarriage and made no active effort to quit smoking while attending the final two meetings.
preparation phase (week 1) included instruction in self-monitoring (cigarettes and smoking urges) and deep muscular relaxation. The quitting phase (weeks 2-3) emphasized use of regular-paced aversive smoking with a concurrent break with usual smoking. The final maintenance phase (weeks 47) provided instruction in methods for coping with and eventually eliminating lingering smoking urges. Audiotapes were used to direct home practice of relaxation and aversive smoking. A printed manual outlined the treatment regimen and served as a permanent reference.*
Results Despite the attendance deposit, group membership diminished over the course of the program. Two women dropped out unexpectedly, one (#6) after attending two meetings and the other (#3) following the fourth meeting. A third participant (#9) experienced a miscarriage at week 3 and continued in attendance while making no further attempt to quit smoking. Data on all participants are summarized in Table 1. Daily smoking was evaluated at onset of pregnancy (via retrospective report), the first and final weeks of the program, and at a 9-month follow-up. Nine of the 11 women reported reduced smoking once they became pregnant. Further smoking reductions were observed during the course of the program for all but three participants. Individual smoking histories for the period following program termination can be considered with respect to two central criteria: 1) abstinence during the remaining period of pregnancy, and 2) abstinence following the delivery date. Of the eight women who attended the complete program and who were pregnant
at termination, three (#5, 7, 10) were abstinent and two (#8, 11) dramatically reduced daily smoking for the remainder of the pregnancy period. Delivery date was a noteworthy time of change for two women with one (# 10) resuming smoking and another (#11) achieving complete and lasting abstinence at that time. One woman (#8) stopped smoking two months after the birth of her child. It is interesting to note that, with the obvious exception of the woman who experienced the miscarriage, all participants gave birth to healthy infants. At the 9-month follow-up assessment, three women were found to be abstinent (#7, 8, 11) and one woman (#5) was smoking less than one cigarette daily. Relatively minor changes were observed in the smoking histories of the remaining participants. Limited sample size precludes identification of significant prognostic indicators, but several interesting associations emerged. Prior experience with birth complications was clearly related to successful performance. A correspondence was also obtained between smoking reduction and diminished consumption of alcoholic beverages during pregnancy.
Discussion
*Available on request to authors.
The present results provide tentative support for the hypothesis that an intensive program of risk education and behavioral skills-training can assist pregnant women to stop smoking. The absolute level of abstinence achieved-both during the remaining period of pregnancy and postpartumranks well above other results reported in the literature. The data further suggest that risk had been substantially reduced for some participants. Optimism must be tempered, however, by several key points: 1) the small sample size, 2) omission of a no-contact
AJPH September, 1978, Vol. 68, No. 9
897
PUBLIC HEALTH BRIEFS
control condition that would measure "spontaneous" quitting, 3) omission of an attention-placebo control condition that would assess the effects of support and encouragement, and 4) the fact that participants were volunteers relatively well advanced in pregnancy. Controlled research is required to develop empiricallytested programs aimed at this special group of smokers. Measurement should focus on recruitment issues in addition to achieving abstinence during pregnancy (when acute risks can be eliminated) and postpartum. In addition to serving immediate public health needs, specially-tailored, effective smoking cessation programs could be used in experimental epidemiologic research to more clearly establish the parameters of risk. Finally, expanded research and program development would directly contribute to a community-wide approach to smoking control.
REFERENCES 1. Larson PS, and Silvette H: Tobacco: Experimental and Clinical Studies (supplement III). Baltimore: Williams & Wilkins, 1975. 2. U.S. Department of Health, Education, and Welfare, Public Health Service. The Health Consequences of Smoking. Atlanta: Center for Disease Control, 1973 and 1976. DHEW Publication Nos. (HSM) 73-8704 and (CDC) 76-8704. 3. Public puffs on after ten years of warnings. Gallup Opinion Index, No. 108:20-21, 1974. 4. U.S. Department of Health, Education, and Welfare, Public Health Service. Adult Use of Tobacco, 1975. Atlanta: Center for Disease Control, 1976.
5. Fielding JE: Smoking and pregnancy. N Engi J Med, 298:337339, 1978. 6. Butler NR, Goldstein H, and Ross EM: Cigarette smoking in pregnancy: Its influence on birth weight and perinatal mortality. B Med J, 2:127-130, 1972. 7. Bergman AB, and Wiesner LA: Relationship of passive cigarette-smoking to sudden infant death syndrome. Pediatrics, 58:665-668, 1976. 8. Colley JRT, Holland WW, and Corkhill RT: Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. Lancet, 2:1031-1034, 1974. 9. Donovan JW: Randomized controlled trial of anti-smoking advice in pregnancy. Br J Prev Soc Med, 31:6-12, 1977. 10. Baric L, MacArthur C, and Sherwood M: A study of health education aspects of smoking in pregnancy. Int J Health Ed, 19: 116 (supplement), 1976. 11. Lichtenstein E, and Danaher BG: Role of the physician in smoking cessation. In Brashear RE, and Rhodes ML (eds.), Chronic Obstructive Lung Disease, St. Louis: Mosby, in press, 1978. 12. Danaher BG: Rapid smoking and self-control in the modification of smoking behavior. J Consult Clin Psychol, 45:1068-1075, 1977. 13. Danaher BG, and Lichtenstein E: Become an Ex-smoker. Englewood Cliffs, New Jersey: Prentice-Hall, in press, 1978.
ACKNOWLEDGMENTS Thanks are extended to W. L. Heinrichs, MD, and R. W. Jeffery, PhD, for their careful reading of earlier drafts of this article. Supported in part by National Institutes of Health Research Service Award (#5 T32 HL 07034-03) from the National Heart, Lung and Blood Institute.
Social Characteristics of Natural Childbirth Users and Nonusers CAROLYN CAVE, PHD, RRA
Introduction Because a significant number of American women apparently want a conscious participation in childbirth,1 psychophysical preparation has become an integral part of childbirth care today. However, some prepared childbirth modes, especially the Read and Lamaze Methods, have continued to cause controversy in American obstetrics, often because these methods are vastly different from maternity care routinely practiced in American hospitals and cited by critics as mechanized,2 dehumanizing,3 or too scientific.4 One might Address reprint requests Dr. Carolyn Cave, Associate Professor and Chairperson, Department of Medical Records Administration, School of Allied Health Professions, Ithaca College, Ithaca, NY 14850. This paper, submitted to the Journal April 4, 1977, was revised and accepted for publication January 24, 1978. 898
say, then, that couples who use natural childbirth in the United States are innovators in the sense that this is an idea perceived as "new" by the patient with newness being in the eyes of the individual.5'6 Findings from previous natural childbirth studies have suggested that social, cultural, and motivational elements need to be identified among natural childbirth users.7 Some have concluded that success with natural childbirth lies in defining the "type of person" rather than merely measuring medical and psychological indicators.8 In light of this, we aimed to define a sociological profile of a natural childbirth user compared with a nonuser of this innovation; findings are compared with other innovation research that explains the "type of person" most likely to adopt a new idea. Compared with later adopters, early adopters have more years of education, are more cosmopolitan, have more knowledge about their disease or illness, are younger, and have a higher inAJPH September, 1978, Vol. 68, No. 9
