Smoking in pregnancy and postpartum

Workshop MINT Forum Sept. 8. Sheffield

Wolfgang Hannöver

Institute for Medical Psychology

2 Wolfgang Hannöver, Institute for Medical Psychology, Workshop MINT Forum Sheffield 2011

Introduction

Who am I?

What am I doing here?

What do I expect from the next 60 minutes?

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Overview

Epidemiology

Efficacy

Theoretical Models

The Transtheoretical Model of Behavior Change

Teachable Moments

MI for pregnant and postpartum women

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Epidemiology

Smoking rates and quit rates in pregnancy:

UK: smoking rates 20 - 30 %

quit rates about 20 % (Owen, 1998)

USA: smoking rates 20 – 30 % (Tong et al., Whalen et al. 2006)

quit rates 30 – 60 % (Tong et al. 2009)

Germany: smoking rates 20 - 40 % (Voigt et al. 2001; Hannöver et al. 2009)

quit rates 20 – 30 % (Hannöver et al.2008)

Denmark: smoking rate 25 %

Netherlands: smoking rate 26 %

Sweden: smoking rate 13 – 15% (Cnattingius 2004)

Relapse rates after pregnancy:

Sweden: 88% 2 yrs (Cnattingius, 2004)

USA: 70 % 1 yr (Colman & Joyce, 2003, Fingerhut et al, 1990, Kahn et al. 2002)

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Predictors for relapse

Older age

Educational level

Lower income

Marital status (unmarried)

No private medical insurance

Multipara (not first child)

High smoking level before pregnancy

Quitting late in pregnancy

Alcohol consumption

Smoking significant others esp. Partner

(Colman & Joyce, 2003; Fingerhut et al., 1990; Kahn et al. 2002, McLeod et al., 2003)

Intention to resume smoking

(Röske et al., 2006; Händel et al., 2009a, b)

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Efficacy

Recent meta-analysis in Cochrane database (Lumley et al. 2009)

Overall effect: RR = 0,94 [0,93 – 0,96]; 6% more abstinent

Incentives: RR = 0,76 [0,71 – 0,81]

CBT: RR = 0,95 [0,93 – 0,97]

Pharma / NRT: RR = 0,95 [0,92 – 0,98]

Stage based: RR = 0,99 [0,97 – 1,00] n.s.

Feedback on infant: RR = 0,92 [0,84 – 1,02] n.s.

Relapse prevention: RR = 0,91 [0,75 – 1,10] n.s

RCTs with MI:

Midwives in two maternal wards in Glasgow counselling pregnant smokers at home ; good quality MI; no effect (Tappin et al., 2005)

Psychologists counsel young mother 4-6 wks post partum, good quality MI, relapse postponed for six months (Hannöver et al., 2007)

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The Transtheoretical Model of Behavior Change

Core constructs:

Stages of change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Processes of change

Decisional Balance (pros and cons)

Self-effiacy

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The Transtheoretical Model of Behavior Change

Stages of change – motivation to change behavior

Precontemplation – no intention to change within forseeable future

Contemplation – intention to change within forseeable future

Preparation – intention and plans for behavior change

Action – behavior is changed

Maintenance – new behavior needs to be maintained

(Relapse) – chance to learn for another attempt

Stages predictive for behavior change, esp. stage-progress

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The Transtheoretical Model of Behavior Change

Processes – it‘s what people do

cognitive-affective processesconciousness-raising dramatic relief environmental reevaluationsocial liberationself reevaluation

behavior oriented processesself liberationstimulus controlcounterconditioninghelping relationshipsreinforcement management

Precontemplation

Contemplation

Preparation

Action

Maintenance

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The Transtheoretical Model of Behavior Change

Dependent variables

Decisional balance (aka Theory of Reasoned Action, Fishbein & Ajzen)

weighing of pros and cons for smoking

weighing of expected outcomes

behavior with expected positive balance becomes relevant

Self efficacy (aka Social Lerning Theory, Albert Bandura)

subjective conviction about ability to perform behavior

stems from

experience

observation (role models)

imagination

emotional condition (physiological processes)

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The Transtheoretical Model of Behavior Change

And in pregnancy?

pregnant quitters

– do not engage in experiencial or behavioral processes associated with action stage

– show less cognitive processing of pro and cons

– report a high self-effiacay for quitting

low levels of process use and high efficacy indicate external motivation to quit

may account for high relapse rates

(Stotts et al., 1996)

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Teachable Moments

„ … naturally occurring life transitions or health events, thought to motivate individuals to spontaneously adopt risk-reducing health behaviors“ McBride et al. 2003, p. 156.

Smoking cessation rates:

Spontaneous: 5 %

Commonly achieved by interventions: 20 % (Curry, 1993)

Health visits: 2 – 10 %

Test results: 7 – 21 %

Pregnancy: 10 – 60 %

Hospitalisation: 15 – 78 % (cf. McBride et

al.)

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Teachable Moments

Cueing

event

Perceived risks and positive outcomes increased

Self concept / social role redefined

Emotion is increased

motivation

akquisition of skills

self-efficacy

smoking cessation

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So, you‘re smoking and you learn that you‘re pregnant

I think: I feel: I do:

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Where is the change-talk? How to evoke it?

„Maybe it‘s a good idea to cut down, but I‘m never gonna quit.“

„It‘s an addiction, what can I do?“

„I like to smoke although it‘s not good for the baby.“

„I really have to quit, now that the baby is on the way.“

„If it weren‘t for the baby, I go on smoking.“

„It‘s the only time I can get away from the baby.“

„I feel like „mom“ is all that‘s left over from me.“

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Complex reflections

„I quit totally in my first pregnancy, but I‘m not gonna make it this time“

Amplified reflection:

„It‘s so

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MI for pregnant and postpartum women

Crucial elements in behavior change:

knowldege EPE

intention motivation ruler

outcome expectancies decisional balance

self-efficacy effectiveness ruler

emotional experience OARS