Smoking in pregnancy and postpartum Workshop MINT Forum Sept. 8. Sheffield

1. Wolfgang Hannöver • Institute for Medical Psychology Smoking in pregnancy and postpartumWorkshop MINT Forum Sept. 8. Sheffield

2. Introduction • Who am I? • What am I doing here? • What do I expect from the next 60 minutes? Wolfgang Hannöver, Institute for Medical Psychology, Workshop MINT Forum Sheffield 2011

3. Overview • Epidemiology • Efficacy • Theoretical Models • The Transtheoretical Model of Behavior Change • Teachable Moments • MI for pregnant and postpartum women Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

4. Epidemiology • Smoking rates and quit rates in pregnancy: • UK: smoking rates 20 - 30 % • quit rates about 20 % (Owen, 1998) • USA: smoking rates 20 – 30 % (Tong et al., Whalen et al. 2006) • quit rates 30 – 60 % (Tong et al. 2009) • Germany: smoking rates 20 - 40 % (Voigt et al. 2001; Hannöver et al. 2009) • quit rates 20 – 30 % (Hannöver et al.2008) • Denmark: smoking rate 25 % • Netherlands: smoking rate 26 % • Sweden: smoking rate 13 – 15% (Cnattingius 2004) • Relapse rates after pregnancy: • Sweden: 88% 2 yrs (Cnattingius, 2004) • USA: 70 % 1 yr (Colman & Joyce, 2003, Fingerhut et al, 1990, Kahn et al. 2002) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

5. Predictors for relapse • Older age • Educational level • Lower income • Marital status (unmarried) • No private medical insurance • Multipara (not first child) • High smoking level before pregnancy • Quitting late in pregnancy • Alcohol consumption • Smoking significant others esp. Partner • (Colman & Joyce, 2003; Fingerhut et al., 1990; Kahn et al. 2002, McLeod et al., 2003) • Intention to resume smoking • (Röske et al., 2006; Händel et al., 2009a, b) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

6. Efficacy • Recent meta-analysis in Cochrane database (Lumley et al. 2009) • Overall effect: RR = 0,94 [0,93 – 0,96]; 6% more abstinent • Incentives: RR = 0,76 [0,71 – 0,81] • CBT: RR = 0,95 [0,93 – 0,97] • Pharma / NRT: RR = 0,95 [0,92 – 0,98] • Stage based: RR = 0,99 [0,97 – 1,00] n.s. • Feedback on infant: RR = 0,92 [0,84 – 1,02] n.s. • Relapse prevention: RR = 0,91 [0,75 – 1,10] n.s • RCTs with MI: • Midwives in two maternal wards in Glasgow counselling pregnant smokers at home ; good quality MI; no effect (Tappin et al., 2005) • Psychologists counsel young mother 4-6 wks post partum, good quality MI, relapse postponed for six months (Hannöver et al., 2007) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

7. The Transtheoretical Model of Behavior Change • Core constructs: • Stages of change • Precontemplation • Contemplation • Preparation • Action • Maintenance • Processes of change • Decisional Balance (pros and cons) • Self-effiacy Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

8. The Transtheoretical Model of Behavior Change • Stages of change – motivation to change behavior • Precontemplation – no intention to change within forseeable future • Contemplation – intention to change within forseeable future • Preparation – intention and plans for behavior change • Action – behavior is changed • Maintenance – new behavior needs to be maintained • (Relapse) – chance to learn for another attempt • Stages predictive for behavior change, esp. stage-progress Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

9. The Transtheoretical Model of Behavior Change • Processes – it‘s what people do • cognitive-affective processes • conciousness-raising • dramatic relief • environmental reevaluation • social liberation • self reevaluation • behavior oriented processes • self liberation • stimulus control • counterconditioning • helping relationships • reinforcement management Precontemplation Contemplation Preparation Action Maintenance Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

10. The Transtheoretical Model of Behavior Change • Dependent variables • Decisional balance (aka Theory of Reasoned Action, Fishbein & Ajzen) • weighing of pros and cons for smoking • weighing of expected outcomes • behavior with expected positive balance becomes relevant • Self efficacy (aka Social Lerning Theory, Albert Bandura) • subjective conviction about ability to perform behavior • stems from • experience • observation (role models) • imagination • emotional condition (physiological processes) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

11. The Transtheoretical Model of Behavior Change • And in pregnancy? • pregnant quitters • – do not engage in experiencial or behavioral processes associated with action stage • – show less cognitive processing of pro and cons • – report a high self-effiacay for quitting • low levels of process use and high efficacy indicate external motivation to quit • may account for high relapse rates • (Stotts et al., 1996) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

12. Teachable Moments • „ … naturally occurring life transitions or health events, thought to motivate individuals to spontaneously adopt risk-reducing health behaviors“ McBride et al. 2003, p. 156. • Smoking cessation rates: • Spontaneous: 5 % • Commonly achieved by interventions: 20 % (Curry, 1993) • Health visits: 2 – 10 % • Test results: 7 – 21 % • Pregnancy: 10 – 60 % • Hospitalisation: 15 – 78 % (cf. McBride et al.) Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

13. Teachable Moments motivation akquisition of skills self-efficacy smoking cessation Emotion is increased Perceived risks and positive outcomes increased Cueing event Self concept / social role redefined Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

14. So, you‘re smoking and you learn that you‘re pregnant • I think: • I feel: • I do: Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

15. Where is the change-talk? How to evoke it? • „Maybe it‘s a good idea to cut down, but I‘m never gonna quit.“ • „It‘s an addiction, what can I do?“ • „I like to smoke although it‘s not good for the baby.“ • „I really have to quit, now that the baby is on the way.“ • „If it weren‘t for the baby, I go on smoking.“ • „It‘s the only time I can get away from the baby.“ • „I feel like „mom“ is all that‘s left over from me.“ Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

16. Complex reflections • „I quit totally in my first pregnancy, but I‘m not gonna make it this time“ • Amplified reflection: • „It‘s so Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011

17. MI for pregnant and postpartum women • Crucial elements in behavior change: • knowldege EPE • intention motivation ruler • outcome expectancies decisional balance • self-efficacy effectiveness ruler • emotional experience OARS Wolfgang Hannöver, Institute for Medical Psychology , MINT Forum Sheffield 2011