Elsevier

Addictive Behaviors

Volume 26, Issue 3, May–June 2001, Pages 405-413
Addictive Behaviors

Retrospective study of the association of stress and smoking during pregnancy in rural women

https://doi.org/10.1016/S0306-4603(00)00118-0Get rights and content

Abstract

Women who continue to smoke during pregnancy put themselves and their fetuses at serious risk for complications. Various smoking cessation programs have been designed that specifically target pregnant smokers. Longitudinal studies, however, have shown that there is a group of women who are unable to quit smoking while pregnant. Women from a rural area of the Mid-West (N=299) were interviewed postpartum to determine the stresses these women experienced prenatally and the association of the stress with continuing to smoke during pregnancy. Subjects were divided into three groups: Nonsmokers, Quitters, Smokers. This study not only confirms other reports that these women are more stressed but also documents some of the major stressors. Statistically significant differences were found between groups for financial worries (P=.0002), problems with the family (P<.001), and domestic violence (P<.001). Assessing pregnant women for stress and, especially, domestic violence should be part of the implementation of the Clinical Practice Guidelines for Smoking Cessation.

Introduction

Among the risk factors for poor pregnancy outcomes, smoking is one of the most dire and one of the most preventable Department of Health and Human Services (DHHS), 1990, Institute of Medicine (IOM), 1985. Smoking cessation programs designed for pregnant women have been effective for some Dolan-Mullen et al., 1994, Floyd et al., 1993, Robert Wood Johnson Foundation, 1999 though, many other women continue smoking despite interventions. For health care providers, it is clinically useful to understand the differences between women who were able to quit for pregnancy and those who continue to smoke.

Smoking during pregnancy is not distinguished by ignorance of the risks. Two-thirds of pregnant women are able to list at least two potential dangers of smoking (Haslam, Draper, & Goyder, 1997). Having a husband/partner who smokes makes quitting more difficult; there is an automatic availability, opportunity, and temptation to smoke. In contrast, having a nonsmoking husband/partner has been identified as being a strong factor associated with cessation success Haslam et al., 1997, Severson et al., 1995, Wakefield et al., 1993. This alone, however, does not explain the differences between those women who quit during pregnancy and those who continue to smoke.

Women who continue smoking during pregnancy perceive more stress in their lives than those who quit Agency for Health Care Policy and Research (AHCPR) & Centers for Disease Control (CDC), 1996, Haslam et al., 1997. Smoking may serve as a coping mechanism for many women (Edwards & Sims-Jones, 1998). A positive correlation has been found between smoking and an increased number of children in the home, having an unplanned pregnancy, having an unemployed partner, experiencing stressful life events during pregnancy, depression, and a perceived lack of control in one's life Dejin-Karlsson et al., 1996, Oakley, 1989. Pregnant smokers often cite “mood control” (stress, boredom, feeling upset) as the reason they could not quit (Haslam et al., 1997). A history of depression is associated with increased nicotine addiction and a decreased ability to stop smoking (Borrelli, Bock, King, Pinto, & Marcus, 1996). In other studies Centers for Disease Control (CDC), 1997, Dejin-Karlsson et al., 1996, Scheibmeir & O'Connell, 1997, Severson et al., 1995, demographic factors known to be stressful, such as low socioeconomic status, education less than 12 years, living alone and low social support, were all associated with women continuing to smoke during pregnancy.

Numerous studies conclude that reasons for continued maternal smoking are more complex than once perceived. Health care professionals in the past have approached maternal smoking as either an addiction or a severe knowledge deficit. At present, however, research indicates that smoking is sustained throughout pregnancy for more than physiological and cognitive reasons. Without underestimating the addictive effect of nicotine, health care professionals can no longer ignore the more recent findings indicating that stress and lack of social support are important predictors of unsuccessful cessation. It is clear that women continue to smoke both for psychological and psychosocial reasons and that programs must include a psychosocial component to see improvement of cessation rates (AHCPR & CDC, 1996).

Since most prenatal smoking cessation studies have targeted pregnant women attending urban-based public or private clinics, it is not known if women who live in more rural areas have the same patterns of smoking and associated stressors during pregnancy. A study was designed to determine the extent of smoking in pregnant women living in a rural area of the Mid-West. The association of stress and smoking during pregnancy was also examined.

Section snippets

Sample

Hospitalized postpartum women (N=299) were interviewed. Two hospitals, in two different nonmetropolitan towns, were used to collect the data between September 1998 and May 1999.

Instruments

The Prenatal Psychosocial Profile (PPP) is a 44-item instrument with four Likert-like scales that measures stress, partner support, support from others, and self-esteem. Likert-like items are rated using a scale with higher scores indicating more of the variable measured (higher stress, more support from partner or

Discussion

Thirty percent of the rural women interviewed were smokers, a rate similar to that reported by the American College of Obstetrics and Gynecology (ACOG) (1997) and Windsor et al. (1993). In a Health Maintenance Clinic (HMO) in Los Angeles, Ershoff, Quinn, and Dolan-Mullen (1995) found a slightly lower rate of 23% prepregnancy smokers in their sample. This lower prepregnancy smoking rate could be related to a difference in the demographics of women attending the HMO clinic compared to the public

Summary

Women who continue to smoke during pregnancy have an increased level of stress and low social support from their partners and others, and are more likely to be victims of abuse. Consequently, their self-esteem and, most likely, their mental health, suffers (Borrelli et al., 1996). The PPP and the AAS are excellent tools to use in prenatal clinics to screen patients. Targeting women who have high stress levels and/or are abused will increase the effectiveness of the Clinical Practice Guidelines

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