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In 2000 the World Health Organization conducted research into the health of women in 191 of its member states. The Netherlands ranked 17th, well behind most other European countries.1 The Dutch Institute for Healthcare and Environment reported on the causes of death that occur more frequently among women in the Netherlands than in other European Union (EU) countries. Among these were lung cancer and chronic obstructive pulmonary disease. Smoking prevalence in Dutch women is among the highest in the EU, with this being the main cause of the stagnating life expectancy.2 Between 1950 and 1999—nearly 50 years—23 000 women died of lung cancer. Between 2000 and 2015—just 15 years—it is estimated that 67 500 women will die from lung cancer, nearly three times as many in nearly one third of the time.3
The theme of the European week against cancer (October 2001) was “Women and Tobacco”. For the Dutch Cancer Society this provided an excellent opportunity to generate attention on the dramatic rise in lung cancer among women. Together with its daughter organisation DEFACTO for a smokefree future, the Cancer Society set up a campaign titled “Planning to become a mom? Stop smoking!”
In the age group 25–35 years smoking prevalence among women is approximately 32%.4 The ill effects of smoking will, for most smokers, not have become apparent yet. Knowledge of health risks is apparently not sufficient to provide an adequate motive to quit for many. This makes it a challenge to determine what kind of messages women are prepared to listen to and to act on.
SMOKING AND PREGNANCY
Dutch research shows that 30% of pregnant women quit when they find out they are pregnant.5 However, about one in four smokers continue to smoke throughout their pregnancy. And two thirds of expectant mothers who quit take up smoking again within two months after the birth.6 Most women do not know that smoking influences fertility and that it takes smokers 30% longer to get pregnant than non-smokers. Also, the increased risk of clubfoot7 is not known to most smokers. Neither are they aware of the fact that miscarriages and prematurity can be caused. Women do know that smoking causes lower birth weight, but in general this is not regarded as altogether unfavourable: for many, a small baby means an easy delivery. It is not known that low birth weight is connected with a higher risk of illness in the early years. And finally, it is not commonly known that sudden infant death syndrome may be the result of smoking in the infant's presence.8
Research also shows that women are more susceptible to health messages if they concern their children, provided these messages are not delivered in such a way that the mothers are made to feel guilty.9 The message is best delivered and most credible if delivered by the general practitioner (GP) or obstetrician. However, obstetricians often believe that they are intruding on the privacy of patients if they bring up the subject. And even if the condition of the patient warrants advice to quit, obstetricians are often hesitant to offer such advice. If asked by their patients whether or not they should stop smoking during pregnancy, obstetricians in some cases still tell expectant mothers that a few cigarettes a day won't hurt. The Ministry of Health in the Netherlands has provided a large subsidy to DEFACTO for a smokefree future to set up an intervention strategy for obstetricians, together with a training programme to increase their awareness of the necessity of the intervention.
The image of the campaign the Cancer Society instigated was a poster with the heading “CHILDREN?” and the subtitle “Planning to become a mom? Are you a mother already? Quit smoking”, and showing a crib with a stubbed out cigarette inside (fig 1). During the pre-testing of the campaign women indicated that they were shocked by this image, but that it also made them want to know more about the subject. They also said that considering the subject and the importance for their children, any message ought to be shocking so that women would take notice.
The campaign consisted of posters that were made for the waiting rooms of GPs, pharmacies, and infant health offices. Freecards were distributed through the hospitality industry and radio spots were aired on networks popular with women in the target age group. Several television programmes discussed the subject of smoking and pregnancy.
In order to get media attention the campaign had a rather spectacular start. Body painters were asked to let themselves be inspired by the subject and make paintings on huge pregnant bellies (see cover). Seven pregnant women were turned into live artworks which received widespread media coverage.
In the Netherlands, women who intend to become pregnant take two actions: they stop using contraceptives and start taking folic acid. The Dutch Cancer Society and DEFACTO for a smokefree future set as their objective a third goal for women: to quit smoking.
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