Health psychology smoking during pregnancy
Discuss the use of health psychology to make sense of the behaviour of smoking during pregnancy. Use identified theories or models from literature and consider what light these throw on the situation.
Smoking is attributed as a cause of around 100,000 or close to 20% of all deaths in the UK with lung cancer as the biggest killer at 40,000 (Baggot, 2004:15). Morbidity from smoking is seen as causing over 250,000 hospital admissions each year due to other chronic diseases such as high blood pressure, respiratory infections and lung disease which are associated with the habit, (Department of Health, 2001). Similarly passive smoking is seen as a related factor in many diseases. Due to the low rates of survival from smoking related diseases prevention has been the object of health strategies related to smoking.
While smoking generally is linked to a number of diseases smoking during pregnancy has been associated with risk not only for expectant mothers but with increased health risks also for the unborn infant. A range of research has demonstrated the wide number of risks and disorders accompanying women who smoke while pregnant.
The range of disorders associated with smoking and pregnancy are wide. Smoking has been associated with the failure of oral contraceptives. It is said to double the chances of spontaneous abortion (Nusbaum et al, 2000). Smoking during pregnancy is also associated with neo-natal weight problems and has been linked with increased chance of Sudden Infant Death Syndrome (Valanis et al, 2001, Pomerleau, Brouwer and Jones, 2000).
Each of these elements alone are diseases which most pregnant women have fears about and wish to avoid, including amongst those women who smoke and while many are able to quit more do not quit successfully or not at all (Bane, Ruggiero, Dryfuss and Rossi, 1999). Numerous public awareness and public health campaigns have been conducted outlining the general medical risks associated with smoking and individual campaigns about the dangers of smoking while pregnant have also been conducted, yet even with these campaigns smoking rates remain high as well as the incidence of smoking related diseases (Boreham and Shaw, 2000).
The fact that smoking cessation strategies for woman have mostly been less than wholly successful from the research with both low take up rates for cessation and high recidivist rates for smokers is an issue of grave concern, (Secker-Walker et al, 1998). It highlights inadequacies within clinical practice when a broader view of the influences on behaviour in relation to disease and illness is not considered. As such despite statistics, medical advice and evidence to the detrimental effects of smoking during pregnancy it remains a feature and a problem of natal and maternal health.
Such behaviour may seem unreasonable to clinicians but a reading and understandings gained from theoretical insights in the field of health psychology shed light and understanding on the behavioural reasons and motivations as to why women smoke during pregnancy. The traditional dominant bio-medical model within medicine offers little insight into behaviours which are non pathological (Engel, 2002). This is the case not only in seeking explanations into smoking but also for other lifestyle choices associated with a higher risk of illness.
The bio-medical model can be accused of reductionism, of seeking explanations to illness and disease which are isolated to single simple causative agents (Curtis, 2002). This model still dominates many areas of health care due to its effectiveness at times in specific instances of disease. Yet in considering an event such as continued smoking during pregnancy the major inadequacies of the model can be highlighted and pointed out. These can be seen primarily as not considering the broader psychological and social factors dealing with illness and disease, (Ogden, 1996, Talyor, 1995). Arising out of the criticisms of the bio-medical model theories generally from psychology were found to have an explanatory value and predictive merit when applied to problems associated with health and illness. It thus led to the emergence and articulation of a new model, a biopsychosocial model (Ogden, 2002).
The emergence of the biopsychosocial model then has had major implications for understanding the behaviour of people both before illness commences, during and also after illness. This model can be seen as a systems model, which is non-reductionist by virtue of the fact that it considers a wide range of variables, biological, social and psychological in explaining the behaviours of people that might cause illness and how people view the illness process itself (Stroebe and Stroebe, 1995). As such developments in health psychology can be seen at times as critical of mainstream beliefs concerning health and the role of individuals in their health (Stam, 2002). Yet while it has been critical it can be argued that a much better view is to see the insights gained from health psychology as being complementary to an in-depth and detailed analysis of individuals and their health (Pitts and Philips, 1998).
Health psychology has emerged since the 1970s and it arguable that it has become a valuable resource in both predicting health and as a part of the clinical process. Its utility as an aid for understanding disease and predicting importantly in regards to the current topic of smoking during pregnancy in order to analyse success or failure of strategies of prevention are manifest. In relation to this a number of predictive models illustrate in contrast to the reductionist bio-medical model the various influences and interactions which determine not only patient’s behaviours but also critically their health status.
Health psychology’s contribution to an understanding of smoking behaviour during pregnancy can be found by considering social cognition theories and the understanding of the various motivations and influences at play in determining which behavioural patterns individuals decide to follow. These social cognition theories thus have a predictive value also in explaining people’s behaviours (Conner and Norman, 1995). While we can acknowledge the addictive nature of nicotine and the fact that such addictions are a disorder we need to be aware as models from health psychology inform us of the complex social and psychological factors which influence behaviour surrounding this addiction, (Cohen et al, 2003).
Each of the models that are examined here are models which from a health psychologists perspective help towards explaining which behaviours are being follow and begin an analytic process by which the reasons for these behaviours are being followed. As such each of these models seeks to provide an explanation of the various cognitive variables explaining people’s actions, what are the intentions towards actions and the expectations which guide decisions on following a behavioural pattern. These social cognition theories have been through research shown to display varied yet successful results as an aid towards understanding the behaviours of individuals.
Health Belief Model
This model is perhaps the oldest and most widely spread used model in the field of health psychology arising out of theoretical advancements in the 1970s. It has been researched to some degree within a clinical setting, with reasonably successful results and thus displays a moderate level of applicability.
The health belief model is comprised of two aspects, perceptions of threat illness and subsequent evaluations of behavioural patterns in response to these perceptions. By analysing these variables then clues as to the possible behaviour as well as the reasons for following these behaviours can be arrived at. We can see the applicability of this theory in relation to smokers generally and women who smoke about the perceived likelihood that the individual will suffer from cancer. Public health strategies which seek to emphasise the frequency of cancer rates can be seen as a response to and incorporation of this model (Conner and Norman, 1998:8-9).
This model has been criticised on a number of grounds generally centred on its failure to include more sophisticated analyses of certain factors or the ability to refine its analyses of certain factors.
Health Locus of Control
Arising out of social learning theory this model proposes a function whereby client’s behaviours are affected by expected results flowing from following a course of action and the degree then to which these results are matched. Simply stated this theory believes that an individual’s decision on a course of action is dependent on how likely it is believed that a particular reinforcement will occur and concurrently what value the individual places on this reinforcement. The primary component of this model is the interactions between various factors which influence how much an individual perceives themselves to be in control over their own health (Curtis, 2002).
This belief orientated model has been criticised mainly on the reliance it places on individuals valuing their health. For those who do not value their health it has been proved inadequate and indeed even in considering the effect on women smoking during pregnancy the limitations of using this model are easy to see.
Protection Motivation Theory
Critical to this model are the concepts of threat appraisal and coping appraisal. The threat aspect relates to how likely it is seen by the client that illness will be forthcoming by following a set behaviour and in turn this is linked by a consideration of how will the person will be able to deal with the illness (Conner and Norman, 1995). This model has been applied with some success to the predictions of certain health behaviours and its utility in understanding smoking during pregnancy is quite high. Indeed by using this theory we can see how the two strands of women’s concerns while pregnant, i.e. To give up smoking for the sake of their pregnancy versus the need to continue smoking are played out against each other.
While PMT has been a successful model in ways this success has detracted from its utility as the model now exists with numerous variations and revisions and the lack of a relatively singular articulation of what the model constitutes is a concern for those wishing to apply the model to clinical practice.
Theory of Planned Behaviour
This is a complex model which seeks to consider a number of key factors which influence the behaviour of clients as well as providing clues as to why certain behavioural patterns are favoured more than others. Developed from the theory of Reasoned Action this model proposes analysing the various influences on an individual’s behaviour and seeing what are the resultant actions flowing from these influences. Control is a key element of this model, or the idea of how much control the individual concerned is able to exercise over their actions in relation to the behaviours they wish to follow.
Similarly the model provides an analysis of the proximal determinants of behaviour by highlighting intent to engage in that behaviour and a client’s perceptions of control over that behaviour. Intention in this model forms as a result of attitudes, individually held norms and perceived behavioural control and represents a person’s motivation in their attempt to resolve the behavioural influences. Perceived behavioural control is an individual expectation that performance is under the client’s control, and this factor is influenced by both internal and external factors.
As a result, individuals are likely to follow a particular health action if they believe that behaviour will lead outcomes which they value, if they believe that people whose views they value think they should act the behaviour and if they feel that they have the necessary resources and opportunities to perform the behaviour, (Conner and Norman, 1998:12-13). This model seems to be an effective one in relation to explaining smoking during pregnancy. However in contrast to other models this one has a relatively weak conception of the role of health threats’ (such as that of the HBM model) which in terms of women’s fears over pregnancy and complications with pregnancy might be construed as a weakness.
Self-efficacy theory relies on the premise that human motivations and actions are based on three kinds of anticipations: situation-outcome, action-outcome and perceived efficacy. Situation-outcome expectancies are related to beliefs about what consequences will occur an example of this would be the perception of threat from a health risk which might motivate the person to consider different actions to minimize that risk (action-outcome expectancy is the belief that a given behaviour will or will not lead to a given outcome (Conner and Norman, 1998). Self-efficacy expectancy is the belief that a particular behaviour is or is not under the individual’s control. It is assumed to have a direct impact on behaviour and an indirect effect through their influence on intentions.
Self-efficacy theory have been found to be important predictors of a rage of health behaviours yet some limitations have been expressed in relation to a wider consideration of social influences related to the various outcome expectancies.
Models and their Utility for Understanding Smoking while Pregnant
When examined together then it can be seen that a variety of viewpoints exist within health psychology as to the causes of behaviour and the various influences and interactions which produce these behavioural patterns. In regards to smoking the variety of influences and reasons for why people smoke in particular the reasons as to why pregnant women smoke reveal the limitations of the bio-medical model. While nicotine dependence is a feature of the disorder other factors need to be considered if a truly successful strategy of prevention can be introduced with real benefits to pregnant women who smoke.
From the outlines above we can begin to see the utility of these models as an aid towards explaining the behavioural patterns of women who smoke during pregnancy as well as for smokers generally. In the case of women smoking during pregnancy there are as the literature suggests a number of specific variables to include, such as expectant mothers fears over the health of their baby and indeed even concerns with marital strain (particularly if the partner of the women is smoking also), (Wakefield et al, 1998).
In a review of TPB in relation to adolescent smoking Wilkinson and Abraham (2004) suggested that while TPB provided clues as to the reasoning behind certain behavioural patterns more extrinsic factors needed to be taken into consideration. In their review peer pressures as well as self-esteem related issues were identified as other critical factors.
Similarly Pomerleau, Brouwer and Jones’s study (2000) demonstrates how esteem, in this case related to perceptions of weight and weight related issues of esteem played out in relation to smoking. As they state “When smokers become pregnant they are asked to control weight gain and at the same time to relinquish an addictive drug with weight suppressing effects” (760). Here we can see how contradictory factors are at play in pregnant women’s decision to continue smoking or failure to successfully quit the habit. Successful applications of cessation strategies would seem as Bane et al (1999) suggest need to take account of the balances applied to decision choices made and thus seek some way to alter the different balances involved in order to promote smoking cessation.
The main contribution of these models therefore is to move us beyond a simple bio-medical conception; it supports the tendency of a move away towards viewing smoking as a completely aberrant behaviour. Smoking is reflective of broader social tensions, the internalisation and calculation of risks associated with a certain lifestyle as well as being an addictive disorder. As such while individual explanations of motivations are important the social context of smoking, the link with smoking with poverty, of educational attainment level and other links between this and other social factors places smoking into a context around which hopefully a comprehensive cessation strategy could be developed.
The health psychology contribution thus to clinical treatments for women who smoke during pregnancy receive an added depth of consideration. While successful use of the models continues to be researched it would seem that these models have a central place in understanding why women smoke during pregnancy. And with this understanding the ability to assist and encourage and support maternal cessation strategies for smoking which are successful can arguable be seen as a feature of maternal health care in the future.
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