Increasing the Uptake of Smoking Cessation Services in Pregnant Woman

1. Increasing the Uptake of Smoking Cessation Services in Pregnant Woman

2. Background Smoking in pregnancy can lead to low birth weight, premature birth, miscarriage and is a contributory factor to infant mortality Women who smoke during pregnancy are likely to be younger, single, low income, have few educational qualifications, live in disadvantaged areas Uptake of the Stop Smoking Service by pregnant women is currently low and work is needed to encourage more to take up the service Amaze was asked to undertake research within the target group and also with health professionals to understand the issues relating to tobacco use and stop smoking services with pregnant women/partners

3. Research Objective The main objectives of the research were:- To understand the issues relating to tobacco use and stop smoking services with pregnant women and their partners

4. Research Objectives And in so doing we were to establish:- • Values, beliefs and awarenessof smoking and pregnancy/ health issues in general • Do pregnant women want to receive help to stop smoking and how do they want this help to be provided • Awareness of NHS Stop Smoking Services generally and Services in their area • Perception of what help is available from NHS Stop Smoking Services (i.e. offerings) • What information do pregnant women want to receive about smoking cessation and stop smoking services, and how they want to receive this information (what channels)

5. The Approach The project was wide ranging in terms of what was covered and who was interviewed; this included the professionals:- • Neighbourhood health worker • Health inclusion equality co-ordinator • Extended services managers • Children’s Centre managers • Children’s Centre co-ordinators • Midwife team leader • Mental health development team for BME communities • Health visitor • Health development specialist – physical activity • Health development specialist – tobacco • Specialist advisor – smoking cessation • Health co-ordinator • Specialist stop smoking advisor

6. The Approach And the target groups themselves:- Mums – groups and depths BME mums – groups and depths Mums who were pregnant – groups and depth interviews Interviewed across the whole of East Lancs. Including a mix of backgrounds A wide range of ages of both men and women Interviewed as individuals In pairs In groups In home And out of home

7. The People Our brief suggested the need to focus specifically on the harder to reach:- • And it’s this segment which might well prove to include the harder to convert smokers too • Because here we saw East Lancashire, warts and all • Here we met the deprived and the depressed • The less well educated, the less well adjusted • And here we talked to professionals about life working with this target group • Where two weeks in a relationship can lead some 16 year olds to think it’s time to plan a baby • Where aspiration is not exactly a by word • And inspiration for the day starts with Jeremy Kyle with a fag and a brew

8. The Places We experienced the differences from location to location:- • So Clitheroe could feel quite leafy and cosy • Colne, though, a little less salubrious • And Burnley town centre at night, well, interesting is one word for it • Sometimes initial impressions could hide a multitude of sins too • And sometimes you needed to get behind the landlord’s reasonable looking curtains • To see just how the real people we were after actually lived • Where floor-covering and wallpaper are not always a given • And where flat screen TVs are a must have for all &

9. The Project This was where our perinatal project sometimes met our work with routine and manual workers and BMEs:- • So cultural norms have a strong part to play • You might be pregnant but that doesn’t mean you stop liking smoking • You enjoy it, it occupies you, it de-stresses you, it is you • And just because there’s a baby inside you it doesn’t mean you think of it as a baby • It’s a bump… a thing • It’s not real yet • It’s not yet really a part of me… • And ‘they’ don’t really know what damage can be done, not to me personally • And giving up smoking just for nine months is hardly going to be worth it, is it?...

10. The Smoking Thing Call it justification, call it rationalisation, call it post-rationalisation, smokers have their reasons for carrying on:- • The fag’s a treat – cos I don’t drink you see • It’s an addiction – what can I do, been smoking since I were 13 • It’s something to look forward to – between looking after the other kids • A stress reliever when you’re trying to get them into bed – do it yourself, I’m going downstairs for a fag • A this, a that or the other… • There was always a reason to continue smoking…

11. So Why Stop? Plenty of ‘evidence’ to call on:- • It never affected anyone years ago, they’ve been all right… • My sister smoked through pregnancy and her kids are ok • Everyone’s born with cancer cells but then they blame cancer on smoking • I don’t mind giving up but I don’t know how it’ll affect the way I am • Will I be able to calm down, what will I be like with the kids

12. So Why Stop? … And More:- • I’m not ready to give up and where’s your proof that it’ll make any difference? • I know I’ve not got a major problem with smoking… • I’ve cut down but to do more would cause more stress – I’m worried enough • It’s only nine months – I’ll have sixteen years of them here when I can give up • The ‘evidence’ caused no concern and provided no reason to stop smoking • They were more bothered about what will happen to themselves/their life if they stop • Some tried to cut down, the thought of quitting entirely, the stress would be unbearable • With many believing that the stress on the baby from them would be worse than cigarettes

13. So Where is Your Proof? And make it 100%:- • Because if it’s not, I’m not listening • People have been getting onto me for years • So why should I do what ‘they’re’ saying now • Who says ‘they’ do know?... • I’ve heard that ‘stress is bad for the baby and giving up smoking causes stress’ • In order to give up you need to not only have will-power (and I’m rubbish, me) • But you also need to want to give up yourself (and I don’t at the moment, ta) • The messages need to be proven, yes ‘stress is bad for the baby’. • But do they knowwhat happens to the baby, can it be proved to them directly?

14. ‘They’ Have a Lotto Answer for ‘They’ say things they can’t always prove:- • Like smoking: • Stunts baby’s growth • Reduces birth weight • Increases risk of cot death • Higher risk of something wrong with baby • Lowers fertility rates • But look at the people I know – no problems there • And what about my mum, and his mum, and my mum’s mum… • The messages might be out there but they’re not necessarily having the desired effect • Many don’t believe the ‘facts’ due to no personal experiences of the ‘consequences’

15. The Types Emerging Professionals at forefront of tryingto influence ante-natal decisions tell us who they come across:- • Where reactions to messages vary, sometimes leading these same professionals to feel like they’re banging their heads against brick walls • There are the procrastinators – maybe I’ll give up one day • The active deniers – can’t prove, won’t listen • The passive refusers – like it, enjoy it, don’t want to stop • The justifiers – it’s for my stress levels and that’s got to be good for the baby • The can so will – I can afford it as well • All present their own challenges to health professionals (e.g. midwife, GP, clinic, nurse…) • And perhaps this multi-faceted system is part of the problem itself…?

16. The Message? Don’t smoke and/or don’t smoke when you’re pregnant?:- • In a world where messages about stopping smoking are felt to be prevalent • Messages about stopping smoking whilst pregnant can be diluted • To a point where some clearly manage to shut themselves off from it completely • And at a time when so much information is being thrust towards you generally • About the birth, the set-up around pregnancy, the appointments… • It’s easier in some ways to put the smoking whilst pregnant thought to one side • Then you light up and the baby kicks… • Well maybe that’s a message worth listening to… • Advisory messages can get lost amongst ‘stop smoking’ and ‘information’ about pregnancy

17. The Mixed Message? • It seems that parts of the passive smoking message have indeed ‘worked’ Smoke in air bad, smoke in body?:- Jordan, four, can quote the ‘I’m not scared of Becky Slater’ advert word for word, clinging to her mum’s legs as she has a ciggie But Jordan’s mum thinks that smoking in the air is different to taking smoke into her body And the Jordan’s mum we’re talking about has a new baby too Born 11 weeks premature, at a birth where mum and baby both nearly died But reassurance was given – it was nothing to do with her, the placenta gave way… …So pass me a fag…

18. The Mixed Message? • Interesting to compare this tale with that from a frustrated midwife Smoke in air bad, smoke in body?:- Just been involved in a case where a placenta had comeaway; baby whose mum had smoked, died – midwife felt the mum ‘had been warned’ but ‘it was as though we hadn’t said a word’…

19. The Midwife Factor Midwife as messenger:- • Ways of the midwife can lead to varied responses • Take-out from the mums to be is that midwives are duty-bound to ask if you smoke • They then ask if you want to do anything about it • And they encourage you to at least cut down • Which I have… • As a last resort, they are encouraged to ‘cut down’, which some do

20. The Midwife Factor Midwife as messenger:- • Talk to the midwife who says she sometimes feels that she’s tried everything • With varying levels of success • One shock tactic had ‘worked’ for one…sort of… ‘Well, when I said I was pregnant she took me into a room and said imagine this room was full of smoke - that’s what you’re doing to your baby I didn’t like it at the time but I didn’t smoke during any of my pregnancies Still smoke now, mind…’ • The one tactic that worked described exactly what they were doing to the baby

21. The Midwife Factor Making the connection:- • Midwives have spotted a need to help mums link pregnancy with actual living thing She said have you just had a cigarette and I said how do you know She said your baby’s heart beat’s slowed down So next time I had a fag half an hour before, rather than ten minutes…

22. The Midwife Factor Making the connection:- • Try, try, try, some are clearly more ‘selfish’ than others • This a word used by many a professional on this topic • Who have witnessed demands from mums which can be described as “aggressive” and “unreasonable” • So who’s going to suggest to these people that smoking isn’t the best way forward for mum and baby?...

23. The Risk Factor For midwives, for mums to be:- • Making suggestions to mums can’t be easy • Especially about how they live their lives, how they plan for their baby’s lives • This is more marked in a world wherein attitudes to risk aren’t necessarily representative of the world at large • These people have their own view on what’s risky and what’s not • What’s done and what’s not done

24. The Risk Factor For midwives, for mums to be:- • So if there’s nothing concrete in your argument then I’m unlikely to listen at all • And even if your argument is concrete I still might choose not to listen anyway • You come round here with your do this, don’t do that • You don’t ‘know’ and you don’t know me • Mums to be seemed reluctant to take and act on advice from professionals

25. Delivery Issues Talk to the midwife and delivery’s the thing pre-birth:- • Mother to be ‘bombarded’ with information galore • And first mums in particular have difficulty imagining beyond the birth itself • How much will it hurt, will I be able to cope • At this stage, then, the post-baby period tends to get somewhat overlooked • As does the physical reality of the baby itself

26. Delivery Issues Talk to the midwife and delivery’s the thing pre-birth:- • So if your mind’s less on baby and more on delivery, planning for baby’s wellbeing isn’t always to the fore • And as we heard from several quarters, young mums in East Lancs. can be more selfish than selfless • So this too can further influence thoughts on contemplation, preparation and action

27. An Issue Amongst Many Lifestyles suggest decision to stop smoking will be one ‘priority’ amongst many:- • Like where am I going to live • Will the dad decide to stick around • Where will I get money from • How will it affect my benefits • Some of this offset by the feeling that – • Others seem to manage • Others tell me smoking won’t matter • Others tell me smoking will help keep the baby’s weight down • And actually in stressful times like this I feel like I need/deserve/want a fag even more… Maybe I’ll give up when baby’s born…

28. Catching On Smokefree homes message has been getting through:- • These women talk about smoke free homes • And those with other children have started to adjust smoking behaviour • This is not easy given nature of habit and habits of lifestyle • Now I only smoke in the kitchen, there’s no door but you can see how it is • When me mate comes round we smoke on the step and leave the kids inside • Friends and family, though, can have a lot to answer for • Always someone willing to suggest smoking’s ok • Always someone ready to say, oh go on, have one…

29. Timing Issues When we study how and why smokers quit, timing can be crucial:- • As Prochaska and DiClemente tell us, five key states of change exist • There’s pre-contemplation; not even thinking about it • Contemplation; thinking but done nothing • Preparation; planning to act • Action; made a move but not a habit • Maintenance; established a behaviour but not committed • Pregnancy itself can throw all of these states into chaos • And an unexpected, unplanned pregnancy is likely to affect this even more … Spin the wheel, how will fortunes roll?…

30. Accessing Services Being pregnant brings appointments aplenty:- • Add this to people who don’t always keep a diary • So accessing smoking cessation appointments would be another one to slot in • And haven’t we got enough to think about?... • This, though, can often represent another potential ‘excuse’ for these mums to put in the way of giving up smoking • It links with the ‘I’m not ready’, the ‘I’m too stressy’, the ‘you can’t prove’ Positively, even if many are not willing to give up, several are prepared to, and do cut down.

31. Down to One, Down to None If there is a propensity to cut down, we need to take them a step further:- • But one to none can feel like as big a challenge, if not more of a challenge than going from twenty to ten • The gap between ‘smoker’ and ‘non-smoker’ can feel like one that many don’t feel able and/or willing to bridge • This is me, this has been me for years • These are my friends, this is my family… This is my life…..

32. Outside, Inside Plans can be considered post-baby time, pregnancy time can feel different:- • Some already say that once baby’s born, fags are taken outside, not in • And they’ve done that for baby before – until it’s been one… • Need to build on such work and relate this to baby as real and living, not just baby as bump and as thing • The message is getting through that smoking around baby’s not great

33. Outside, Inside Plans can be considered post-baby time, pregnancy time can feel different:- • The next step is adding the notion that passive smoking internally is just as bad if not worse • We’re talking literal people who need things spelling out in one syllable – • “do this, baby sad…” • The drip, drip effect has worked to a greater and lesser extent But there are foundations here on which to build – it’s not all gloom, it’s not all doom

34. Strategy Targeting women who are pregnant who also happen to smoke:- • Some might say the rules of engagement don’t need to change at all • Smoking bad, stop it • They’re still women, they’re all at different stages (i.e. pre-contemplation etc) • So why should being pregnant make them feel any different • For them, the baby doesn’t necessarily feel real yet – • Can’t kiss it, can’t cuddle it, can’t smell it, can’t love it?... • And we’re often talking selfish people here • Selfish people who can also feel ‘got at’, ‘singled out’, ‘targeted already’ even

35. Strategy Pretence to presence:- • Somehow then we need to have these people think baby inside, not doll, not thing • We need them to recognise that blowing smoke out isn’t the only issue involved when it comes to ‘passive smoking’ • Somehow they need to be persuaded and ‘educated’ that smoking from the inside is a big problem too – smoking bad for baby, stop it… • And this is bad for baby in the here and now, not just the potential future…

36. Strategy Stop Smoking Services:- • Ask pregnant smokers about accessing stop smoking services and various images come to mind • Some seem to conjure up a vision of sitting in groups announcing, ‘I’m Jennifer and I smoke 30 a day’ • Others imagine facing the doctor or talking to a nurse at a clinic • The majority, though, imagine this is something they might have to face alone or face with a group of other people they probably don’t know • Most thought that they would have to try and quit on their own or with strangers

37. Strategy Stop Smoking Services:- • Out of this comes the idea that quitting at the same time as others they know might be worthy of consideration • So you and your best mate make a pledge together • The family agrees that now they’re all going to try it together • For pregnant mothers, this might allay some of the fears that they’re facing everything alone New baby, new life, new world of not being a smoker…

38. Strategy Time management:- • Ironies exist in lives with no diaries but which feel very full • Where chaos seems to reign in places where not much seems to be going on • Where several speak of boredom as a reason why they smoke • But in the next breath claim they have no time for more appointments • When they’re being targeted by all and sundry • Interesting that activities which flow from having a new born • Can sometimes be held up as reasons why new mums have cut down their smoking • Less time on their hands, then, less time to think smoke…

39. The Battle Plan Current Implementation – Strengths & Weaknesses Education – Plugging the Gaps Communication – What, To Whom, How

40. The Battle Plan- Pregnant Smokers - Current Implementation • The hard to reach pregnant smokers find it very easy to find reasons why now would not be a good time for them to give up • They often feel they have enough on their plate already, thank you very much • So weaving in another appointment pre-birth, especially one which might feel hard to stomach – is not something they’re too keen to hear about • So the ante-natal information pack gets raided first for the word on benefits, the rest may or may not be accessed at all • As for stop smoking services, they can blend into general health messages about being a perfect mum • And that’s fine for other mums, they don’t have my debt worries, housing troubles, partner issues • Back off, I’m having a baby…

41. The Battle Plan- Pregnant Smokers - Education • A gap definitely existing between passive smoking around kids and smoke outside the body • And passive smoking for baby inside the body • This not helped by the fact that often ‘selfish’ mothers fail to make connection between bump, lump, thing growing inside their body is real, is living, is smoking when they smoke • There seems to be a, some might say, convenient lack of biological knowledge surrounding baby in womb and baby emerging beyond the womb • Just because they can’t cuddle it doesn’t mean it’s not living and growing… • This is a message that needs spelling out, fast and simple…

42. The Battle Plan- Pregnant Smokers - Communication • A haunting image exists, as described by one young mum • ‘Then one day I lit up and I felt the baby kick’ • Here was someone describing the transformation between recognising she was having a baby and realising that the baby had feelings too • So what was going into her body was without doubt affecting the growing baby within • Baby knew, baby kicked, baby suggesting not happy • It’s this kind of simple message which needs relaying to these types of mums to be • Not necessarily ‘shock tactics’ but tactics which put a clear message across • Like the midwife who shut a mum in a room and asked her to imagine the room filled with smoke • This got the message home too, though maybe in a more direct way…