The media coverage of the Government White Paper, Choosing Health: Making healthy choices easier (DoH 2004d), illustrates arguments for and against the banning
Box 12.3 Effects of passive smoking on babies and infants
Intrauterine growth restriction Increased mortality
Sudden infant death syndrome Meningitis
Glue ear
Lower education attainment Leukaemia
Reduced lung:body ratio Respiratory disease More hospitalization
Smaller and lighter at 5 and 7 years More visits to GPs
More likely to be a smoker
(Raw et al. 1998, DoH 2000, Twigg et al. 2004)
152 Smoking, pregnancy and the midwife
or restriction of smoking in public places. Comparisons are made with Scotland, Ireland and New York where bans have already been enforced. Supporters of a ban cite cases of lung cancer resulting from secondary or passive smoking and suggest that a partial ban is not enough (Roberts 2004); opponents consider the evidence insufficiently robust and claim that the economic and social effects will be negative.
Some suggest that the Government is creating a nanny state with intrusion into every aspect of our lives to limit our eating, alcohol intake, gambling and smoking. The reader can access some of the arguments via websites for ASH (2004) and FOREST (2004) (see also Useful information and contacts). In this potentially confusing and authoritative context, midwives are required to raise awareness on health issues so that women and their partners can be supported to make lifestyle decisions to benefit their own health, the health of their family and that of the forthcoming baby.
To approach women in the right manner, we need to acknowledge our prejudices and try to suspend judgement. It is easy to say that everyone knows that smoking is harmful and anyone who smokes must be foolish. Are we all so perfect that we do nothing potentially harmful to our health? Ideally none of us would actively choose to behave in ways detrimental to our health, but human nature is such that at some time most of us have behaved inappropriately.
When women who are planning to conceive or are pregnant tell us they smoke it can evoke many feelings. Maybe in light of the reflection we can rethink how
‘foolish’ or ‘wrong’ we feel they may be and consider more clearly the action that could be taken to help them stop smoking.
But what if the midwife smokes? Is she a hypocrite telling pregnant women to stop?
Her defence may be that she is not pregnant. Perhaps she cannot raise the issue, so maybe we need to support her in quitting (Wiseman 2004). However, the midwife who is a former smoker can empathize, and appreciate the addiction and difficulty of quitting; she may have used many of her clients’ arguments to justify not stopping, e.g. ‘I will not be a drain on the state as I shan’t live to draw my pension’, ‘Tax paid on
Reflection – 1
Examine your own life and identify a time when you have been tempted to act (or have acted) without full consideration of your health, e.g. eating poorly, driving too fast, not exercising, having unprotected sex, drinking to excess.
Make notes when considering these questions:
• Why did you do it?
• How did it make you feel?
• Did you think about the possible risks?
• Did you know what the risks were?
– if yes why did you still do it?
– if no would you still be tempted knowing it was possibly unsafe?
Think about your response to campaigns about your health-threatening activity?
If you cannot recall a situation that fits this reflection, perhaps someone you know has, so try imagining their responses to these questions or better still ask them!
Attitudes towards tobacco smoking 153
cigarettes pays for the health care needed’, ‘My auntie/mother/father has smoked 30 a day since a teenager and is OK’, ‘My last baby weighed 7 lb’, and can defuse their impact. The woman may be encouraged by the midwife’s success in quitting and remaining a non-smoker, so strategies can be discussed more personally. The financial implications of smoking are another factor that non-smoking midwives find hard to accept when the family may be struggling to make ends meet, as is evident from the statistics linking social deprivation to substance misuse (DoH 2004c).
The non-smoking midwife needs an empathetic, not a critical judgemental approach to assisting her client; quitting is very difficult, so we need to adopt positive messages (Rew 2004). Consider the busy woman pregnant with her second or third baby, whose partner, family and peers smoke, and who feels that her only solace in a frantic day is to sit for a few minutes ‘having a fag’. Maybe a carrot rather than a stick will help her; we can acknowledge the difficulties but encourage her that by feeling fitter she can be more active with her children, and dream how she can spend the money saved. Saying she smells like an ashtray or instilling even more guilt than she already feels will alienate some (Rew 2004) and scare-mongering tactics may encourage a defiant lighting up!
Additional costs highlighted by the midwife could include home decoration, air fresheners, laundry and housework, and more dental hygiene. These may be persuasive arguments for some people, but even so some women will forego their food to pay for their cigarettes.
Social isolation exists for smokers: they are increasingly ostracized as a danger to others’ health and for their unpleasant odour. For some equating their smell with sitting next to someone with severe, stale, body odour on crowded public transport may be a revelation. Quitting may reactivate dormant friendships with non-smokers with the simultaneous exclusion from smoking peers and the loss of the camaraderie that they shared. It is hard for even the most enthusiastically supportive midwife to compete with some of the pressures, so sustaining the woman’s non-smoking status needs active support from her partner and friends.
Motivation can be further encouraged by visual cues of damage with raised carbon monoxide levels in expired air, a falling lung expiratory capacity, a baby’s bottle full of cigarette ends floating in tar, pictures of lungs impregnated with tar and smoke, and babies exhaling smoke. These may have some immediacy, whereas cancer rates and long-term debility seem remote when the smoker enjoys the habit now.
The presence of a pregnancy or planning a pregnancy may be sufficient motivation for the woman and her partner to stop smoking. For most smokers motivation is the key; once in place it provides the impetus to quit often helped by NRT. Once stopped, ex-smokers need much support and encouragement from the midwife and everyone around them to stay stopped, but the short- and long-term effects (Table 12.1) of quitting can sustain them.
Activity – 1
Access the HDA website (www.hda.nhs.uk) and estimate the purchase costs and levels of dependence for a real or imagined client. See how much money she could spend on alternatives in a week, month or several years if she quit.
154 Smoking, pregnancy and the midwife