There is no doubt that there is a link between smoking and social class. It seems that the greater the level of socioeconomic depriva- tion, the higher the rate of smoking. In England, smoking rates are lowest in the South at around 24%, but highest in London and the North, at around 29% (White and Watt 2002).
Unfortunately, sociodemographic patterns also follow suit in pregnancy. Trends in the UK indicate that women of a young age (under 20) with a poor education, low income, low employment status (i.e. unemployed or in manual work) are more likely to continue smoking during pregnancy (BMA 2004). Other factors include marital status, parity and age (Hutchison et al. 1996).
Dorsett and March (1998) found that a single mother on benefits and living in council accommodation, with a poor level of educa- tion has an 80% chance of being a smoker (BMA 2004). Previous experience is also likely to influence women in pregnancy. Women who have smoked during a previous pregnancy are also less likely to quit, especially if the birth went without complications and the infant is healthy (BMA 2004).
54 Essential Midwifery Practice: Public Health
However, the main socioeconomic factor highly associated with smoking in pregnancy is poverty, with the poorest women being the likeliest to smoke (Penn and Owen 2002). Bridgewood et al.
(2000) highlighted this relationship by demonstrating a gradient in smoking prevalence with social class. In social class I, around 15% of men and 14% of women smoke cigarettes. In social class V, smoking prevalence reaches 45% for men and 33% for women.
This transcends into very high levels among the deprived groups, where smoking prevalence reaches over 70% and is about 90% in homeless people sleeping rough (Bridgewood et al. 2000). Linked to poverty and financial situation is, of course, employment status.
Women in manual work are four times more likely to smoke dur- ing pregnancy than those in non-manual work. It has been shown that just 4% of professional women smoke, compared with 26% in lower-skilled occupations (BMA 2004).
Poverty also affects children’s exposure to second-hand smoke.
Jarvis and Wardle (1999) also reported that 54% of babies and young children from poorer backgrounds are exposed to passive smoking, compared with 18% of those from more affluent back- grounds (Action on Smoking and Health (ASH) 2006a). Graham (1993) further highlighted the effects of poverty on smoking in single mothers by reporting reasons such as ‘I smoke more if I’ve got bills coming in’ and ‘I tend to get worried. Like Christmas is coming and I’m not able to afford things I want.’
Family and peer influences
Family and peer groups have the greatest influence on people who smoke and midwives should appreciate this. The biggest influences appear to be having a partner who smokes, friends of the opposite sex, having a sibling who is a smoker and the social influences of parents and peers (O’Callaghan et al. 1999; Penn and Owen 2002). Influence of peer groups has also been cited on numerous occasions as a major cause for the adoption of smoking in adolescents. Another train of thought suggests that peer pres- sure may be an uncertain factor for causing smoking behaviour.
It may be that young people simply associate with adolescents of similar backgrounds and interests who smoke (Eiser et al. 1989).
In pregnancy there appears to be a link between social class and smoking rates of partners. Pregnant women whose partners worked in manual employment were more likely to smoke than those with partners in non-manual work (Penn and Owen 2002).
Smoking in Pregnancy 55 Another interesting finding is that even though parents them- selves may smoke, they more than often disapprove of their chil- dren smoking (Eiser et al. 1989) and parental opposition is often stronger for girls than boys, but there is still a major public health issue for children who are exposed to second-hand smoke.
Passive smoking
In the UK, 42% of British children live in a household where at least one person smokes (ASH 2006a). Passive smoking has been well documented as a cause of bronchitis, pneumonia, and coughing, wheezing, asthma attacks, middle ear infection and possibly cardio- vascular and neurobiological impairment in children (ASH 2006b).
Studies have also associated exposure to second-hand smoke with sudden infant death syndrome (Letson et al. 2002). A con- fidential enquiry into stillbirths in the UK concluded that in house- holds where only the father smoked the risk of cot death increased 2.5 times (Royal College of Obstetricians and Gynaecologists (RCOG) 1996).
The United Kingdom has approximately one in five pregnant non-smokers who cohabit with another person who smokes and who are therefore exposed to second-hand smoke during pregnancy (BMA 2004). It is estimated that second-hand smoke causes more than 17 000 children each year to be admitted to hos- pitals in the UK with respiratory illnesses. The cost of this care has been approximated at £167 million, based on prices as of 1997 (BMA 2004).
Passive smoking still also remains a public health issue in pregnancy, even though research has revealed a strong public opinion that pregnant women should be protected against it, as should children and people with asthma and heart disease (Christakopoulou and Dawson 2004). A review of the evidence conducted in the US by the Surgeon General’s office concluded that on average, infants born to women exposed to second-hand smoke during pregnancy are 40–50 g lighter than those born to women who are not exposed (BMA 2004). This may not seem to be very important at birth, but there is an increasing body of knowledge that suggests that being born small has an effect on your health for the rest of your life, Barker et al. in 1992 first put forward the theory that babies who had intrauterine growth retardation were at increased risk of early mortality in adulthood from obesity, diabetes and coronary heart disease. This influence will be discussed later in the chapter.
56 Essential Midwifery Practice: Public Health
Second-hand smoke in the workplace can also affect pregnancy, even when this exposure is relatively low. In pregnant non- smokers exposed to second-hand smoke, it is estimated that the risk of having a low-birthweight baby is increased by 20%
(BMA 2004).
Pregnant women who are exposed to other people’s cigarette smoke might also be raising their baby’s risk of developing cancer in childhood (Sorohan et al. 1997a). Many countries, including the UK, have now agreed to ban smoking in the workplace and in pubs and clubs to protect workers from second-hand smoke.