Reducing and Preventing Tobacco Use Among Pregnant Women, Parents, and Families
Bonnie L. Halpern-Felsher
Department of Pediatrics
University of California, San Francisco
Joan K. Orrell-Valente
Department of Pediatrics
University of California, San Francisco
REDUCING AND PREVENTING TOBACCO USE AMONG PREGNANT WOMEN, PARENTS, AND FAMILIES
Parent smoking poses health risks to children in utero and beyond. This risk may actually increase over time when one considers the cumulative effects of risk to the fetus from maternal smoking during pregnancy, exposure to household environmental smoke, and the fact that parent smoking predicts child smoking. Parents rightly represent a prime target for tobacco cessation interventions.
In this appendix, we provide an overview of the risks to children of maternal smoking during pregnancy, of exposure to household environmental smoke, and of becoming a smoker if parents and/or siblings smoke. We also identify factors associated with parent smoking versus parent cessation. An understanding of these factors can be useful in guiding the design and implementation of more effective interventions. Throughout, we provide a review of intervention efforts aimed at preventing or reducing tobacco use. We conclude with a set of recommendations for future prevention and intervention efforts.
SMOKING DURING PREGNANCY
Despite known risk factors, rates of smoking among pregnant women remain alarmingly high. Data from the United States Vital Statistics shows that approximately 13 percent of women smoke during pregnancy (Ventura et al. 2000). Analysis of data from the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (PRAMS) for 1993 through 1999 showed that rates of smoking among pregnant women declined from 15.8 percent in 1993 to 12.3 percent in 1999 (Colman and Joyce 2003). The data also indicated that, on average, 26 percent of women smoked 3 months prior to pregnancy during the 1993–1999 period of data collection. Data from the 1998 National Health Interview Survey (NHIS) indicated that 19 percent of the women reported smoking at the beginning of their last pregnancy, and almost 12 percent smoked at some point during their pregnancy (Yu et al. 2002).
Rates of tobacco use during pregnancy vary by women’s age, ethnicity, socioeconomic status (SES), and region of residence (Pickett et al. 2003; Ventura et al. 2000; Yu et al. 2002). Most tobacco use among pregnant women occurs in white women, women of low SES and/or educa-
tional level, and women who initiated smoking during their adolescent years (DiClemente et al. 2000; Goldenberg et al. 2000; Pickett et al. 2003; Yu et al. 2002). Tobacco use among pregnant women also occurs at greater rates among women who engage in other harmful health behaviors, are most heavily addicted to tobacco, and have the fewest psychosocial resources to overcome the addictive behavior (e.g., DiClemente et al. 2000; Goldenberg et al. 2000). It is perhaps important to recognize that these women represent a population subgroup that may be most resistant to cessation efforts given that they appear to have opted to smoke despite prevailing anti-smoking social norms and messages concerning the harm of smoking in general and during pregnancy (DiClemente et al. 2000).
Maternal smoking remains the single most important modifiable cause of poor pregnancy outcome in the United States, accounting for a significant proportion of babies with low birth weight, pre-term births, and perinatal deaths such as sudden infant death syndrome (SIDS) (Orleans et al. 2000). Such negative effects have been shown to occur even at moderate levels of smoking (e.g., less than eight cigarettes per day). Further, studies have shown that maternal smoking during pregnancy contributes to a range of health and developmental complications for children, including changes in fetal brain and nervous system development, respiratory illnesses, ear infections, language delays, higher activity, increased tantrums, and lower social competence (e.g., Anderson and Cook 1997; Ashmead 2003; Di Franza and Lew 1995; Faden et al. 2000; Slotkin 1998; Wisborg et al. 1999). These risks related to maternal smoking prompted the Healthy People 2010 objective to reduce smoking rates among pregnant women to no more than 2 percent (DHHS 2000).
Smoking Cessation During Pregnancy
Many women quit smoking at some point during their pregnancy, with most cessation attempts occurring upon first learning about their pregnancy status (e.g., Pickett et al. 2003). Cessation efforts may be permanent, limited to the duration of their pregnancy, or sporadic during pregnancy, while other women simply reduce their amount of smoking. Data from the PRAMS study showed that an average of 42.5 percent of the women quit smoking at some point during their pregnancy, with quit rates increasing from 1993 through 1999 (Colman and Joyce 2003). Data from the NHIS 1991 Pregnancy and Smoking Supplement showed that while almost 40 percent of the pregnant women quit smoking for at least 1 week, almost half of these women resumed smoking at some point during their pregnancy (Pickett et al. 2003; see also Yu et al. 2002). Quit attempts were most prevalent in the first trimester, although attempts at smoking cessation occurred throughout the pregnancy.
Quit rates among pregnant women vary by demographic factors, with cessation more likely among adolescents, older women, women at first pregnancy, more educated women, Hispanic women, women with lower nicotine dependence, and women who smoke fewer than 10 cigarettes per day (Colman and Joyce 2003; Pickett et al. 2003; Yu et al. 2002). Low SES also appears to be a primary characteristic that distinguishes women who quit from women who continue smoking during pregnancy (e.g., Panjari et al. 1997; Quinn et al. 1991). Importantly, these women are subject to the cumulative stress of the range of physical and psychosocial conditions that are associated with lower SES. They are known to have more emotional problems, less social support, fewer financial resources, and residential instability (Paarlberg et al. 1999; Panjari et al. 1997). Too often, the pregnancy may have been unplanned, possibly resulting in the woman viewing her pregnancy as an additional stressor. Tobacco use may represent, in effect, a way of coping with stress.
Unfortunately, there are few intervention efforts aimed at getting pregnant women to stop smoking. Most of these efforts are brief, office-based interventions incorporated into prenatal care visits and have been shown to have minimal effect (Orleans et al. 2000). Despite guidelines emphasizing the need for clinicians to treat tobacco use during pregnancy through repeated screening, counseling, and treatment, few clinicians even inquire as to whether a pregnant woman is smoking, and inquiries are generally limited to the first visit, with follow-up inquiries rarely occurring (e.g., Pickett et al. 2003; Orleans et al. 2000). Studies show, at best, moderate rates of provider delivery of tobacco screening and counseling services, with services declining dramatically over the course of pregnancy and postpartum. Orleans and colleagues’ (2000) review showed that less than one-half of medical providers routinely screened and advised their patients about smoking, and less than one-third discussed smoking cessation with their patients who smoked (Orleans et al. 2000). Pbert and colleagues (2004) found that whereas 52 percent of patients reported that their obstetric clinician intervened at the baseline prenatal visit, only 19 percent reported intervention at the 9-month prenatal visit, while 13 and 15 percent, respectively, reported intervention by their pediatric clinician at the 3-month and 6-month postpartum visits. Given very high postpartum relapse rates (Carmichael and Ahluwalia 2000; Fingerhut et al. 1990; see more information below), it is clearly not enough to intervene only once and only early during pregnancy. Even when clinical providers do inquire about smoking, a significant proportion of pregnant smokers do not accurately disclose their smoking status to their obstetric providers, so no intervention is ever attempted. Estimates go as high as 15 to 20 percent, prompting calls to include cotinine screening as part of routine prenatal screening procedures (Walsh et al. 1996; see also Owen and McNeill 2001). Even when the best clinical practices are implemented, studies indicate that fewer than 20 percent of addicted smokers succeed in quitting (Orleans et al. 2000).
One recent intervention study found that for the most at-risk population of low income pregnant and postpartum women, a relatively low level of social support from a nonsmoking friend or acquaintance identified by the women and modest financial incentives donated by local health care organizations were effective in smoking cessation (Donatelle et al. 2000). Thus, interventions that work in the context of these women’s lives to reduce stress appear to be of benefit. It is further suggested that these women may benefit from learning more adaptive ways of coping and receiving interventions that focus also on the development of a sense of self-efficacy, which is likely to be necessary for smoking cessation.
Quit Together was a randomized controlled trial of a smoking cessation intervention aimed at getting low-income pregnant women to quit smoking during pregnancy and to maintain smoking cessation postpartum (Ma et al. 2005; see also Pbert et al. 2004). In the intervention, health care providers were trained to implement national clinical preventive service guidelines based on the pregnant woman’s readiness for change. Services included routine screening; reminders to providers to provide services; distribution of materials to the patients; follow-ups; and coordination among providers in obstetrics, pediatrics, and the Women, Infants, and Children (WIC) program (Ma et al. 2005). Controlling for demographic characteristics related to smoking cessation (e.g., age, ethnicity), women in the intervention group were more likely to quit smoking during pregnancy and to be abstinent at time of delivery than were women receiving usual care.
Tobacco cessation efforts have also been found to be subpar at the institutional level. An evaluation of 76 federally funded programs to reduce infant mortality rates among high-risk women shows that these programs fail to identify tobacco cessation activities as a high priority,
are poorly funded, have inadequately trained staff, and have few intervention materials (Klerman et al. 2000).
Taken together, the high rates of smoking among pregnant women as well as the low rates of sustained smoking cessation during pregnancy, along with the lack of effective interventions, present an important call to action. These findings speak to the need for the development of more clinical preventive guidelines for the continual screening, education, and treatment of tobacco use among pregnant women throughout the entire pregnancy. Moreover, the results strongly suggest the need for clinician training and education in implementing the clinical guidelines. Finally, it is clear that in addition to health professionals providing clinical preventive services, cessation tools should be made readily available to the pregnant woman directly.
Rates of Smoking Relapse Postpartum
For women who quit smoking during pregnancy, postpartum relapse rates are alarmingly high. It is estimated that up to 70 percent of women resume smoking within 6 months of giving birth. Data from the PRAMS study indicated that more than half of the women who quit smoking during pregnancy went on to smoke again between 2 and 6 months postpartum (Colman and Joyce 2003). Relapse rates were highest among adolescents, less educated women, women who smoked more than 10 cigarettes prior to pregnancy, and low-SES women (Mullen et al. 1997). Concern over such high rates of postpartum relapse stem not only from the continued harm to the mother, but from the effect of secondhand smoke on the child and the entire family (see below).
Probable explanations for such rates of postpartum relapse are based in the transtheoretical Stages of Change Model (Prochaska and DiClemente 1992) and in the theory of extrinsic versus intrinsic motivation and behavior (DiClemente 1999). There is evidence to suggest that the primary motivation for spontaneously quitting smoking during pregnancy is centered on the health and well-being of the fetus, and not necessarily the health of the mother or the improvement in the overall household environment (e.g., McBride and Pirie 1990). Similarly, one primary thrust of tobacco cessation efforts aimed at expectant mothers is the reduction of fetal risk. The birth of the baby essentially obviates this extrinsic motivating factor, and the mother (who is adjusting to the stress of a new baby) can rationalize both smoking resumption and protection of her child by not smoking in the presence of the baby, (e.g., going outdoors). Of note also is that pregnant women who spontaneously quit smoking during pregnancy exhibit process-of-change characteristics that suggest that they are not deciding to quit smoking but to suspend smoking temporarily. These women appear more akin to nonpregnant women in the contemplation or preparation stages of change than they are to nonpregnant women who are in the action stage of quitting smoking. It would appear that a focus on the range of benefits that accrue from quitting, which include intrinsic benefits to the mothers, may be more effective in relapse prevention.
Interestingly, although the Quit Together intervention described above, in which the specific delivery of the intervention was based on the patients’ age and level of addiction, did have success in terms of the cessation rates during pregnancy and at time of delivery, participants in the intervention group were no more likely than patients receiving usual care to maintain smoking abstinence postpartum (Ma et al. 2005). Results from their process evaluation suggested that the lack of intervention effect on postpartum smoking rates was due largely to lack of continued intervention as well as limited focus on postpartum support to continue smoking cessation. Their results strongly suggest the need to create a system of continued support and clinical guidelines for smoking cessation postpartum.
A potent influence on smoking during pregnancy and risk for relapse after pregnancy is having a partner who smokes. Expectant mothers whose partners are smokers report less support to quit and less likelihood of quitting than expectant mothers whose partners were nonsmokers (e.g., Ko and Schulken 1998; McBride et al. 1998). Evidently, partners must be included within the purview of tobacco cessation efforts. In fact, Project PANDA, an intervention consisting of videos and newsletters mailed to women during the final weeks of pregnancy and the first 6 weeks postpartum, included such a component, also mailing intervention materials geared to the male perspective. This intervention showed significant success with the women through the 12-month follow-up. Compared to controls, men were significantly more likely to be abstinent at the 3-month follow-up, though not at later follow-up (Mullen et al. 2000).
REDUCING EXPOSURE TO SECONDHAND SMOKE
Not surprisingly, the most important source of environmental tobacco smoke exposure of young children is parental smoking (Jordaan et al. 1999). National data indicate that almost 40 percent of U.S. children under the age of 5 live with at least one parent or guardian who smokes. Children who are regularly exposed to environmental tobacco smoke are at greater risk for a variety of respiratory ailments including asthma, bronchitis, and pneumonia (AAP 1986; Di Franza and Lew 1996; Etzel 1997; Gortmaker et al. 1982; Mannino et al. 1996). These children also miss more days of school due to illness than children of nonsmokers (Mannino et al. 1996).
To date, there have been few attempts to reduce children’s passive smoke exposure. In fact, Emmons and colleagues (2001) identified only four such interventions. These interventions tended to target new mothers, were delivered by pediatric clinicians, and consisted of self-help written materials. They were not effective. Objective measures of children’s exposure to tobacco smoke showed that the interventions had no significant outcomes. More success was observed with Project KISS (Keeping Infants Safe from Smoke). This project compared a motivational intervention with a self-help intervention. The motivation intervention targeted parents of children younger than 3 years old, was delivered to parents in the home by a health educator, and consisted of a 30 to 45-minute motivational interviewing session and four follow-up telephone counseling calls. The self-help intervention consisted of a mailed smoking cessation manual, tip-sheet, and resource guide (Emmons et al. 2001). Nicotine levels were significantly lower at 3-and 6-month follow-up for parents participating in the motivational intervention. No decrease in nicotine levels was observed in the parents in the self-help condition.
Despite the lack of formal interventions aimed at increasing smoke-free homes, studies have examined the extent to which parents are placing restrictions on smoking in their homes. Across studies, findings indicate fewer than 40 percent of the homes studied were smoke-free. Household smoking bans were more likely to occur in houses in which there were children and when at least one parent was a nonsmoker (Ashley et al. 1998; Okah et al. 2002; Pizacani et al. 2002). Clearly, more work is needed through public health messages as well as through health care providers to educate adults and children about the effects of secondhand smoke and to encourage smoking bans in all households.
PARENT SMOKING AND PARENTING BEHAVIOR AS A PREDICTOR OF YOUTH SMOKING
Despite theories in the lay and scientific arenas suggesting that peers wield the greatest influence on children’s and adolescents’ behavior, the scientific evidence indicates that parents in fact
remain a very important influence on adolescent development and behavior (e.g., Collins et al. 2000; Kerr et al. 1999). This may be the case in part because friendship groups change over time whereas parents generally remain a stable entity and force in adolescents’ lives.
Studies have consistently demonstrated an association between parent smoking and adolescent smoking (e.g., Chassin et al. 1996; Flay et al. 1998; Fagan et al. 2005; Jackson and Henriksen 1997; Simons-Morton et al. 2004; Tilson al. 2004). Chassin and colleagues (2005) have found that general parenting style with regard to parental behavioral control and acceptance prospectively and uniquely predicts adolescent smoking. Specifically, engaged parents relative to disengaged parents were less likely to initiate smoking. Interestingly, this effect was not explained by parents’ smoking-specific practices (Chassin et al. 2005). As these researchers point out, the results suggest that parenting interventions may be more effective if broadened beyond a focus on smoking-specific practices.
The primary parenting mechanisms that have emerged as related to adolescent smoking are parent role modeling and parent monitoring. The thrust of both parent modeling and monitoring is centered in parents’ explicit and implicit communication of antismoking socialization of their children. Moreover, Bauman and colleagues (1990) found that parent lifetime smoking is actually more strongly related to adolescent smoking than parent current smoking, suggesting that the association cannot be explained simply as the child imitating the parents (Bauman et al. 1990). As Bandura (1986) has noted, however, “… modeling (is) one of the most powerful means of transmitting values, attitudes, and patterns of thought and behavior” (Bandura 1986, p. 47). Indeed, parents with a history of smoking tend to hold and communicate weaker antismoking beliefs to their offspring, to be less likely to have household smoking rules (Kodl and Mermelstein, 2004), to see themselves as less influential in their children’s decision to smoke, and to be more likely to see adolescent tobacco use as inevitable (Clark et al. 1999). In addition, it is important to note that the risk rates for children of former smokers are similar to the risk rates for children of current smokers, suggesting that parent modeling effects may be resistant to parents’ quitting smoking. As pointed out by Jackson and Henriksen (1997), this may be the case either because parent’s behavior change is not accompanied by similar change in their fundamental smoking beliefs or because parents do not use their behavior change as an opportunity to convey strong antismoking messages to their children. An extremely relevant finding is that children are less likely to smoke when parents engage in antismoking socialization even when parents are current smokers (Jackson and Henriksen 1997).
Parental monitoring, as recently reconceptualized and illuminated by Kerr and Statton (2000) and Kerr and colleagues (2000), is based squarely within the domain of quality of the parent– adolescent relationship and parent–adolescent communication. It encompasses a range of knowledge about the adolescent that necessarily comes from the adolescent him- or herself through either voluntary sharing of information; active parent solicitation of information concerning his or her experiences, activities, and whereabouts; or knowing the adolescent’s friends and peers. Clearly, the extent of mutual warmth and trust is directly related to the quality of parent– adolescent communication, particularly as it pertains to risk behaviors (Kerr et al. 1999; Kerr and Stattin 2000). Part of this process includes parental setting of expectations that are clear and age-appropriate with consequences that are fair, affirming, and useful (Connell et al. 1995; Connell and Halpern-Felsher 1995; Halpern-Felsher et al. 1997; Lee and Halpern-Felsher 2001; Kerr and Stattin 2000; Simons-Morton et al. 2004; Stattin and Kerr 2000). Parental monitoring also serves to prevent or reduce adolescents’ health-compromising behaviors through the setting of curfews, awareness of and participation in afterschool and weekend activities, and prevention of adoles-
cents’ association with risk-taking peers (Cohen et al. 1994; Kerr and Stattin 2000; Stattin and Kerr 2000; Steinberg et al. 1994). Research on parental monitoring has consistently and convincingly shown that it is a critical protective factor with regard to children’s and adolescents’ tobacco use (e.g., Andersen et al. 2004; Clark et al. 1999; O’Byrne et al. 2002).
Sibling Effects on Adolescent Tobacco Use
Siblings as a source of influence on adolescent tobacco use have received far less empirical attention than other potential interpersonal sources of influence, such as parents and peers. Notably, however, the available research points to the possibility that older sibling smoking may actually exert a greater influence on adolescent smoking than parent smoking does (e.g., Avenevoli and Merikangas 2003; Boyle et al. 2001), with older siblings influencing not only the level of younger sibling smoking but also their rate of use over time (Duncan and Aber 1997). Even more remarkably, classic twin studies have consistently suggested that initiation and rate of tobacco use may be influenced more strongly by shared environmental factors—social factors that promote sibling similarity—than by genetic factors (e.g., Li et al. 2003). Most recently, Slomkowski and colleagues (2005) utilized the Add Health sample of sibling pairs, representing the range of genetic relatedness, to disentangle genetic from nongenetic effects and to elucidate the sibling relationship dynamics that underlie any social processes (Slomkowski 2005). Both genetic and shared environment were found to contribute independently to adolescent smoking, with social connectedness between siblings moderating the effects of the shared environmental factors. Thus, sibling influence must be recognized as a social risk factor. Prevention and intervention programs aimed at reducing adolescent tobacco use would benefit from research to provide detail on the mechanisms that underlie the sibling effects on adolescent smoking.
Parent- and Family-Focused Interventions to Reduce Adolescent Tobacco Use
Despite compelling evidence showing associations between parent smoking and adolescent smoking, few adolescent tobacco cessation interventions include a parental component. Even less common is research to evaluate the effects of these interventions. Moreover, the intervention studies that have been conducted have serious methodological limitations, including small sample sizes, already-motivated parents, little likelihood of faithful replicability, and assessment of only short-term outcomes.
Focus on Kids (FOK) is a risk reduction intervention that focuses on “naturally occurring” peer groups rather than groups determined by the intervention or investigators. Although this intervention showed some positive short-term effects, its impact decreased over time. The addition of a parental-monitoring component to the intervention, Informed Parents and Children Together (ImPACT), was shown to increase parent–youth communication and adolescent perceptions of parental monitoring; however, ImPACT itself did not have a significant, unique effect on adolescent engagement in risk behavior.
In an extension of this intervention, Stanton and colleagues (2004) conducted a randomized, longitudinal trial in which one group of adolescents received FOK and their parents received a control training, while another group received FOK and parents received ImPACT, and the third group received FOK, ImPACT, and boosters. Results showed that adolescents who received FOK and whose parents received ImPACT were significantly less likely to smoke cigarettes than adolescents exposed only to FOK, indicating that teaching parents to communicate with their
teens and to provide more supervision of adolescents’ behaviors can have a positive effect on adolescent behaviors.
Perry and colleagues (1990) were successful at encouraging parents to conduct antitobacco activities with their children in grades 4 through 6, but the effect of these activities on tobacco use was not evaluated (Perry et al. 1990). Biglan and colleagues (1996) examined the influence of two components of a community intervention on tobacco use. One component involved mobilizing peers, and the other mobilizing parents (Biglan et al. 1996). Results showed positive effects of communication activities geared toward increasing knowledge about and more negative attitudes toward tobacco use. Youth exposed to the antitobacco information were more knowledgeable about tobacco and had more negative attitudes toward tobacco use, reporting lower intentions to use tobacco. The effects on long-term intentions and actual tobacco use were not assessed.
Bauman and colleagues (2000; 2001) evaluated the effect of the Family Matters Program, an adolescent tobacco and alcohol prevention program in which four mailings of booklets were made to families, with each mailing followed by a telephone discussion with a health educator. The program evaluation consisted of telephone interviews at 3 and 12 months post-intervention. Results showed a 25 percent reduction in smoking onset for non-Hispanic white adolescents, with no statistically significant effects for the other ethnic groups. In a subsequent study, Bauman and colleagues (2002) showed that the Family Matters Program had a significant effect on reducing the prevalence rates of adolescent smoking, with effect sizes of 0.19 and 0.17 sizes at the 3-month and 12-month follow-up (Bauman et al. 2000; 2001).
Cohen and Rice (1995) found that asking parents to control risk factors, such as limiting adolescents’ associations with peers who were smokers, had no significant effects on adolescent substance use. This research suggested that relative to risk factors, a focus on protective factors (e.g., parent monitoring of adolescents’ whereabouts, a respectful parent–adolescent relationship with good rapport) might be most beneficial (Cohen and Rice 1995).
Curry and colleagues (2003) implemented and evaluated a randomized trial of a family-based smoking prevention program in a managed care setting. The intervention targeted parents and children aged 10–12 years. In this intervention, a smoking prevention kit was mailed to parents, followed by parent newsletters, telephone calls by health educators, materials for the children, and information placed in medical records and charts as reminders to the physician to deliver prevention messages (Curry et al. 2003). Children were 11 to 14 years old at follow-up. Despite their careful design and implementation of the intervention, evaluation results showed no program effects. Although the intervention had small but significant effects on increasing parent– child communication about tobacco, no differences between the intervention and control groups were found in susceptibility to smoking, experimentation with smoking, or monthly smoking rates. As Curry and colleagues (2003) point out, families in this study were of relatively low risk, and almost all of the parents indicated at baseline that they had talked to their children about smoking. They also admitted that their attempt to engage providers was minimal and, according to patient reports, may largely have failed to follow up. This study suggests that interventions may need to be more intensive to be effective.
SUMMARY AND RECOMMENDATIONS
Reducing tobacco use among pregnant women, parents, and within the family environment will yield dramatic social, physical, and economic benefits. Maternal smoking during pregnancy has been directly linked to low birth weight babies, preterm births, perinatal deaths including
SIDS, and changes in the development of the fetal brain and nervous system. Continued smoking within the home environment also has grave consequences to children as well as adults, including asthma, infections and illness to the ear and lung, and respiratory functioning (see Orleans et al. 2000 for a review).
Recommendations for Prepartum and Postpartum Interventions
Prior to and during pregnancy provides a potentially optimal period for smoking intervention. Not only are women often willing to quit smoking, at least for the sake of their unborn child, but women are also most likely to be encouraged and supported by their family, peers, and medical providers to quit smoking. Unfortunately, current interventions targeting smoking cessation among pregnant women are not optimal, in part due to: (1) the lack of well-developed, effective programs that are ready for mass dissemination; (2) limited adherence to clinical preventive service guidelines; (3) pregnant women not disclosing their smoking status during medical exams; and (4) inadequate programs to address postpartum relapse (Orleans et al. 2000).
Based on the evidence reviewed above, it is clear that early primary prevention of smoking among young women represents our best effort. As such, female smokers should be the target of cessation intervention efforts before, at the beginning of, and throughout pregnancy, as well as postpartum. Not only should obstetric clinicians provide such prevention or intervention services, but pediatric providers should also be mobilized in the delivery of preventive and intervention services. Importantly, cessation programs and services must be sustained even after delivery so as to reduce the likelihood of postpartum relapse. Finally, the expectant mother’s close social support network, especially her partner, should be recruited into the cessation efforts. As such, we recommend the development of more clinical preventive guidelines for the continual screening, education, and treatment of tobacco use among pregnant women throughout the entire pregnancy. In addition, every pregnant woman should be told about the harms of smoking while pregnant and screened for tobacco use. Pregnant women who smoked should be referred to a smoking cessation program, and continual follow-ups concerning maternal smoking status should occur.
Recommendations for Reducing Household Environmental Tobacco Smoke Exposure
There is clear evidence that secondhand smoke is harmful and that many children and youth are at great risk of exposure to secondhand smoke in the home. As such, efforts to eliminate or at the very least reduce such home exposure should be made, with an eye toward making all homes smoke-free. Pediatric providers can and should play an important role in the lives of young children who have no control over their exposure to household environmental smoke. At every medical visit, providers should screen, counsel, and educate parents and children about the harmful effects of secondhand smoke and should discuss with parents the importance of keeping a smoke-free home.
Recommendations for Parenting Behaviors
Research shows a direct link between parenting behaviors and children and youth smoking in two critical ways. First, extensive evidence shows that youth reared in homes in which parents have authoritative parenting styles, including warmth and involvement coupled with clear and firm boundaries, as well as active monitoring of their behavior, are less likely to engage in health risk behaviors, including tobacco use. Second, research shows that youth are more likely to
smoke if their parents or others in the household smoke. These two sets of literature suggest that intervention efforts aimed at reducing youth smoking should contain a parent component in which parents are encouraged: (1) not to smoke, (2) to communicate with their children about tobacco use and convey strong antismoking message to them, and (3) to closely monitor their child’s behavior. Further, pediatricians, obstetricians, and other health care providers should discuss with parents the importance of discussing tobacco use with their children, including conveying expectations that the child will not smoke and the importance of monitoring their children with regards to tobacco use.
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