154 Smoking, pregnancy and the midwife
Strategies for smoking cessation 155
• ASSIST her by offering information and strategies
• ARRANGE referral to smoking cessation services and midwife follow-up.
These four stages can be equated to the Prochaska and DiClemente (1984) trans- theoretical stages of change model, which was developed specifically to assist pro- fessionals to support individuals with smoking cessation:
Precontemplation Ask
Contemplation Advise
Making changes (preparation and action stages)
Maintaining changes Assist/arrange
Relapse stage
Precontemplation
Here the smoker is unaware of problems or has no interest in changing behaviour, so the midwife needs to raise awareness and perception of risks and potential problems.
Contemplation
The smoker appreciates that there is a problem, but has not decided to quit, does not want to limit her pleasure or fears failure. Midwives can help her appreciate some issues around these and why it is good to quit:
• Weigh up the benefits and costs of stopping
• Challenge misinformation
• Discuss worries about giving up
• Discuss methods of support
• Establish existing harm of smoking
• Discuss the function of smoking
• Illustrate with leaflets and information.
Having adopted a positive frame of mind and established a good rapport, to share information about the effects of smoking and benefits of stopping with the woman and her partner, the midwife uses knowledge and skills to spend quality time, perhaps for the first occasion, to address these health promotion issues. Raising the issues may be all that is possible at a first encounter to avoid information overload, but written or pictorial information can reinforce and supplement verbal interaction;
supplies of leaflets and posters can be obtained from the Tobacco Information Campaign. The midwife will use her interpersonal skills to determine the best approach to take at each succeeding interaction to get the messages across.
Making changes – preparation
A single interaction with a pregnant woman is of little value without providing strategies for smoking cessation; involving her partner dramatically improves the quit rate, although HCPs are sometimes ambivalent about addressing smoking issues (Royal College of Midwives (RCM) 2002).
To help prepare the woman it is worth spending time helping her understand why she smokes; this can be achieved by the following:
• Make a smoking diary with the when and why a cigarette is smoked
• Identify high-risk times and strategies to minimize them, e.g. distractions, change of habits such as drinking juice not coffee
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156 Smoking, pregnancy and the midwife
• Explore worries about giving up
• Write down personal goals
• Make an action plan for stopping, with specific achievable targets
• Make part of the home non-smoking
• Explore the use of NRT
• Identify treats and rewards
• Set a quit date
• Tell friends and family
• Talk to a mum who has recently stopped smoking.
These can be supported by attractive literature and leaflets.
Making changes – action
• Throw out cigarette, lighters and ashtrays
• Identify treats and rewards
• Recognize short-term benefits of having stopped (see Table 12.1)
• Have helplines and websites to hand
• NHS Pregnancy Smoking Helpline: 0800 169 9169 from 09:00 to 21:00
• NHS Smoking Helpline for partners or friends: 0800 169 0169 from 07:00 to 23:00
• NHS Direct www.nhsdirect.nhs.uk or telephone 0845 4647, 24-hour service
• Obtain NRT (bupropion is not recommended in pregnancy)
• Use usual midwife as well as specialist smoking cessation midwife, local support group or counsellor.
Withdrawal symptoms such as craving, moodiness and irritability, fidgeting, feeling lightheaded, inability to concentrate, weight gain, constipation and coughing can be explained and minimized by NRT; drinking water half-hourly, snacking on fruit and vegetables not sweets, avoiding large meals, and keeping hands and mind busy will help;
coughing is a reassuring sign that the respiratory system is reactivating its defences.
Maintaining change
Continued support is vital here; motivation may be sufficient to get started, but for some staying stopped is a real challenge:
• Continued support and positive regard
• Bolster self-esteem
• Use of treats and rewards
• Carbon monoxide monitoring for visible benefits
• Identify medium-term benefits (see Table 12.1)
• Use credit card-sized reminders about the benefits
• Arrange text messages of support from friends
• Make at least four appointments for weekly face-to-face support in a group, alone or by phone
• Reinforce reasons for stopping, i.e. benefits to her and her family, how to spend the money saved
• Manage cravings with the four Ds: delay,deep breathe, drink water, do something else, read a magazine, exercise.
Government statistics use a 4-week cut-off for cessation; for pregnant women one hopes that cessation will be permanent in view of the long-term effects on the family, so ideally a follow-up at 12 months from quit date would be good to see if she is still not smoking.
Strategies for smoking cessation 157
Relapse
Regrettably a number of quitters will not succeed, but each time smokers stop, they are a step nearer quitting for life. It takes most smokers several attempts to succeed.
The midwife should be positive about how long the woman has succeeded in stopping, even if only a few hours or days, help her by reiterating the positive benefits of stopping, and review the triggers that caused the relapse to help prepare for the next attempt when the cycle begins again.
Unfortunately many women, successful in pregnancy, relapse in the early postnatal period, but with continued midwifery support and reminders of why she stopped smoking, and reassurance that relapse is common, her self-esteem may be revitalized.
Few smokers succeed in quitting at the first attempt, but the benefits to the mother and her new baby are considerable. Repeat NRT prescriptions are normally delayed for 6 months (NICE 2002) to enable time to determine the cause of the relapse, motivation to return and preparation for the next quit date to be established. Women and their partners should not be made to feel guilty or failures at relapsing, but encouraged that they succeeded for a time and that with each attempt success is more likely (RCM 2002).
Motivational triggers are individual and may sustain women permanently; for others motivation will be short-lived. Once the motivation to stop is identified, strategies can be suggested to realize the goal to quit smoking. The midwife can start these strategies by referring the client to a smoking cessation service or invoked if the midwife is the main HCP involved with the woman in her quest to quit (NICE 2002, West et al. 2000, RCM 2002). Identifying individual strategies for each woman and her family, providing support based on sound knowledge, with good interpersonal skills and encouragement, the midwife can help to achieve the targets set by Government and contribute positively to health promotion for the nation.