Stage of change is associated with assessment of the health risks of maternal smoking among pregnant women

Abstract

This study explored pregnant women’s assessment of the health risks associated with maternal smoking. The aim was to determine if stage of change relating to smoking is associated with risk assessment. A cross-sectional survey (employing a self-completion questionnaire) was conducted of all women who attended antenatal clinics at Leicester Royal Infirmary, National Health Service Trust, UK over a 2 week period. Questionnaires were completed by 254 respondents. Twenty seven percent of non-smokers agreed with more than 75% of a series of statements about the dangers of maternal smoking compared to 5% of smokers and 44% of women in social class I (highest social class) agreed with more than 75% of the statements compared with only 10% of women in social classes IV and V (lower social class groups). Married women were twice as likely to concur with more than 75% of the health risks compared to single or cohabiting women and 29% of women intending to breastfeed agreed with more than 75% of the statements compared with only 8.7% of women not intending to breastfeed. There was no significant effect of age, whether the pregnancy was planned, previous obstetric complications or whether the woman had a child with asthma or respiratory infections. A multiple regression analysis indicated that smokers were much less likely to agree with the health risks than their non-smoking counterparts (p=0.034). Stage of change was related to both the number of health risks agreed with and the level of conviction. A woman’s stage of change could be assessed at the start of antenatal care so that appropriate smoking cessation advice can be offered.

Introduction

Smoking during pregnancy is associated with increased infant mortality and morbidity (Abel, 1984, Cnattingius et al., 1988) and has adverse effects on children’s physical (Goldstein, 1971) and mental (Olds, Henderson & Tatelbaum, 1994) development. The recent UK Government White Paper on tobacco Smoking Kills sets the target of reducing maternal smoking to 15% by the year 2010, with a fall to 18% by the year 2005 (Department of Health, 1998).

To reduce maternal smoking it is important to understand the factors which maintain the behaviour. Lack of awareness of the health risks does not seem to be a contributory factor. Haslam, Draper and Goyder (1997) conducted semi-structured interviews with 200 antenatal attenders and found that two thirds of these women were able to cite at least two health risks. There was no difference in the levels of knowledge of pregnant smokers, ex-smokers and never-smokers. This suggests that smoking during pregnancy is not distinguished by ignorance of the health risks but is more a problem of translating knowledge into behaviour change. However, Haslam et al. point out that the ability to cite health risks associated with maternal smoking does not mean that the individual is necessarily convinced that these risks represent a real threat to the health of their unborn child.

Smokers may perceive antagonism between an appreciation of the health risks and a maintenance of smoking behaviour. Cognitive dissonance theory (Festinger, 1957) states that people desire consistency between their attitudes and behaviour. Where inconsistency (dissonance) exists, the pressure for change should also exist. Dissonance, being psychologically uncomfortable, will motivate the person to reduce the dissonant state. In the case of smokers, they may (a) change their actions, i.e. stop smoking; or (b) change their cognitions about the effects of smoking, by misperceiving the information, denying the validity of it, or otherwise distorting it. The latter may be easier to achieve than behavioural change.

Some studies have shown that women who quit smoking following conception tend to have stronger beliefs in the harmful effect of smoking during pregnancy compared to women who continue to smoke (Quinn et al., 1991, Wakefield and Jones, 1991, Stacy et al., 1994). But the evidence relating to the health beliefs of pregnant women is somewhat equivocal. Wakefield, Gillies, Graham, Madeley and Symonds (1993) found that out of four statements regarding health problems associated with the children of smokers only the statement ‘children of smokers are more likely to get infections’ showed a significant difference with a higher proportion of quitters agreeing with the statement compared to smokers.

In the last decade, Prochaska and DiClemente’s (1982) stages of change model has attracted great interest among researchers involved in the study of health related behaviour such as smoking. Central to the model is the notion that people who abandon health compromising behaviour progress through predictable, well defined stages. The model assumes that behaviour change is a dynamic process involving five distinct stages. These stages are: precontemplation (not even considering changing one’s behaviour), contemplation (thinking about changing), preparation (making definite plans to change), action (here the individual has changed their behaviour) and finally maintenance (working to prevent relapse and consolidate the gains made) or relapse. An individual’s stage of change can be assessed by an algorithm based on the responses to a few simple closed questions. De Vries and Backbier (1994) in a survey conducted in the Netherlands, applied the stage of change model to study the motives of pregnant women who quit smoking or continued to smoke. They found that precontemplators had a more negative attitude toward quitting than the other groups and that those in the action stage (having quit smoking) had encountered more positive social influences for quitting.

Prochaska, Norcross and DiClemente (1994) state that a person’s stage of change determines their receptiveness to different forms of health education. For example, people in the precontemplative stage are more influenced by ‘shock-horror’ or consciousness raising messages whereas skills training interventions are more appropriate for those in later stages (those who have already decided to change). Proponents of this model argue that interventions need to ‘place’ recipients in terms of their stage of change and target information accordingly.

The aim of this study was to determine if a pregnant woman’s stage of change with regard to smoking is associated with her assessment of the health risk relating to maternal smoking. The hypothesis is that women further along the cycle of change will be more convinced of the dangers of smoking during pregnancy. This question is of theoretical significance in terms of the validation of the influential stage of change model and of practical significance to the development of effective antenatal smoking cessation interventions.

It is also hypothesised that factors traditionally associated with non-smoking in pregnancy (high social class, older age groups, being married, having a planned pregnancy and intending to breastfeed) will be associated with acceptance of the health risks of maternal smoking. Finally, the study will explore whether two other factors (having experienced previous obstetric problems and having a child with health problems known to be related to maternal smoking) are associated with acceptance of the health risks of smoking during pregnancy.