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This assignment will look at an 18 year old girl who is two months pregnant, and a smoker. It will be a reflection on a real life situation from practice, so all names and information that could identify the client, will be changed in accordance with the Nursing and Midwifery Council guidelines to protect patient confidentiality (2004). For the purpose of this assignment the client will be called Hannah. Hannah left school at age 15, she lives in a council flat with her parents in Devon, and currently works 16 hours a week in a supermarket. This paper will look at the issue of smoking and smoking during pregnancy, in terms of its epidemiology. The main focus will then be on Health Promotion, and certain models and approaches will be addressed to see what could be useful when trying to promote someone to make a lifestyle change to benefit of their own, and in this case, the health of an unborn child. I will then look at the Government Initiatives and policies surrounding this matter, and any ethical issues that arise from this situation.

In 2006, Action on Smoking and Health (ASH), released a fact sheet stating that over ten million people in Great Britain smoke, which is almost a quarter of the population. This figure undoubtedly includes a number of pregnant women, and according to a survey carried out by The Information Centre for the NHS, 32 per cent of mothers in 2005 admitted to smoking in the twelve months prior to, or during their pregnancy, and 17 per cent of these mothers confessed to smoking through the full term (2007). This shows that Hannah’s situation is not uncommon among pregnant women throughout the UK. It was acknowledged as an issue by the government, and in 1998 the Department of Health (DOH) set a target to reduce the number of women who smoke during pregnancy, from what was then 23 per cent, to 15 per cent by the year 2010 (DOH 1998).

Hannah lives in Devon, and according to the statistics shown on the Department of Health website for the first quarter 2006/07, the south west has the second highest number of females who smoke during pregnancy, totalling almost 12 per cent of pregnancies in the area (2007). The British Medical Association (BMA) has made links between smoking during pregnancy, and women’s educational backgrounds, economic and employment status (2004). Certain statistics show that Hannah’s individual circumstances may have put her at risk of becoming a teenage mother who smokes. Both Hannah’s parents smoke, and there is a direct correlation between children and young people starting to smoke, if they live in an environment with smokers (Fergusson et al 2007).

She left school at age 15, and since then has been working in the supermarket. The BMA say women lacking in education are 10 times more likely to smoke during pregnancy, than women who stay in education until the age of 21 (2004). Studies have shown that around 26 per cent of women in unskilled occupations smoke, compared to only 4 per cent of women with professional jobs (BMA 2004). This indicates that Hannah is likely to be in a working environment where she is surrounded by many other smokers, which could make the process of quitting more difficult.

Communication and education are essential tools in helping Hannah to decide upon taking healthy action. From the statistics linking smoking during pregnancy with a lack of education, it is logical to think that Hannah may be unaware of the dangers of smoking to the unborn foetus, and the health professional’s role would be to ensure that Hannah has all the current information. This will allow her to make an informed choice, with an understanding of the risks and consequences this decision may hold (DOH 2007). Finding out that she had become pregnant was a shock to Hannah, and she struggled to come to terms with this, making her worried, anxious, and feel that she wanted to smoke more. This in tern has made her feel guilty as she may be damaging her baby further.

Erblich et al (2003) suggest that stressful situations cause smokers to increase the amount of cigarettes they have per day, and this need is further increased if they have direct relations who smoke. This helps us to understand why Hannah feels she needs to smoke more, so by informing her that it is common for smokers to feel their cravings increase during stressful periods, it may help to decrease her guilt and anxiety levels, reducing her cravings and need to smoke.

As a Health Professional it is important to recognise how a person is feeling about their situation, therefore with a clear understanding of how Hannah is feeling, we can decide on the appropriate manor in which to facilitate a healthy choice. Giving up smoking had not been something Hannah had considered before the pregnancy, and due to her anxiety it would be inappropriate to frighten her with all the possible health risks she may be inflicting on the baby, as well as on herself.

Ewles and Simnett (2003) stress the importance of talking to people in a non-judgemental way, and recognising how to discuss the advantages of stopping unhealthy behaviours without condemning the behaviour as immoral (2003). So instead of speaking to Hannah about the dangers of smoking, making her aware of the health benefits for herself and the baby, such as feeling more active, a decreased risk of respiratory problems, premature birth and cot death (BMA 2004), may mean she starts to think about making a life style change, and stopping smoking for good. Thus benefiting her own, and the child’s health.

Littlell and Girvin (2002) discuss Prochaska and DiClemente’s (1984) Stages of Change model as a useful aid in trying to help adolescents and young people give up smoking. By educating Hannah about the benefits of a smoke free life for herself and the baby, she may begin to contemplate the possibility of giving up. With continued support and education from us as health professionals she should ideally progress through to making a commitment to stop smoking. Once this decision has been undertaken it is important to empower Hannah and make her feel in control of her health.

Rotter (1954, cited Naidoo and Wills 2000) stresses how important this is, as people who are willing to accept responsibility for their own health are more likely to respond to health promotion, than those who are not in control and feel powerless. The feeling of being powerless can often occur when someone perceives themselves to have ‘failed’ because they have relapsed (West 2004), Hannah herself is convinced that she will not be able to give up smoking, so is dubious about making the change. The stages of change model is useful in helping to develop an understanding of the change process (West 2004), letting Hannah see that it is not uncommon for people to relapse and that this should not be disheartening, encouraging her to continue through the change cycle.

Hannah’s self-esteem is very low, due to her anxiety about her pregnancy and the smoking, so the advice given to help facilitate her giving up cigarettes needs to be tailored around this. By helping to empower Hannah, and raise her self esteem, she will be more likely to decide upon taking healthy action, and with self belief it is probable that she will continue not to smoke (Naidoo and Wills 2002). There is a strong belief that a high level of self esteem is linked to motivation (Ewles and Simnett 2003), and that quitting depends on motivation as treatments to assist people giving up are not likely to work without it (West 2004). This implies that someone who is highly motivated to make a change is more likely to action and sustain it. This concept is reflected in the Health Action Model, which looks at boosting self confidence, and helping to build life skills in order to resist outside pressures and influences (Ajzen and Fishbein 1980, cited Ewles and Simnett 2003). In her home, working and social life, Hannah is surrounded by smoking, so it is important that she feels she can be assertive and confident, resisting the temptation and possible pressure she may be under to smoke.

This means as well as helping to empower Hannah, it is also very important to inform her of aids to help the quitting process and, to help her establish an environment which helps to assist her healthy choice. Hannah smokes 30 cigarettes per day, and worries how she will cope when she attempts to quit. She may be unaware of the services and aids available to her, as health professionals it is our job to educate and promote them. McNeil (2004) discusses the use of Nicotine Replacement Therapies (NRT) as means of minimising health risks, as these pose much less threat than smoking itself. NRT used to be very expensive, but in 2001 the Government made it available on NHS prescription (DOH 2007). As Hannah is on a low income, this means that she can receive the treatment for free, should she wish.

The ideal would be for Hannah to stop smoking entirely and not to use NRT, as there may be adverse effects of pure nicotine on the function of the placenta and the developing foetus (Molyneux 2004). However, the long term risks are still thought to be far lesser than that of smoking, due to the sheer volume of carbon monoxide and other chemicals in cigarettes which the foetus would be exposed to, so with the advise of a Health Professional it may be that NRT is an appropriate way to move forward for pregnant women (Molyneux 2004).

By making Hannah aware of the possible risks and advantages of NRT, and recommending her to visit her local smoking cessation advisers, she will be able to make an educated decision about what would be most beneficial for her and the baby. In comparison to non-pharmacological interventions and ‘cold turkey’ quit attempts, NRT leads to around double the cessation rates (Molyneux 2004). These figures should be encouraging for Hannah, and help her to maintain self confidence should she attempt to quit with this as an aid.

Between the years 2003 and 2006 the government made £138 million available for the NHS stop smoking services, and this money was used to give additional counselling training to certain pharmacists and nurses, who would then have roles as smoking cessation advisers within each Primary Care Trust (DOH 2007). Added to this was an additional £6 million between the years 2001 and 2003, but this money was to be specifically put towards the smoking in pregnancy initiatives, allowing training for a number of midwives, ideally at least one within each primary care trust, who could then solely focus on the needs of pregnant smokers (DOH 2007). This is ideal for Hannah, as she has the possibility to liaise with a midwife who is qualified to counsel her in her individual needs, and is aware of many other women in Hannah’s situation.

The smoking cessation advisers hold one to one sessions, and for pregnant women they will do home visits if they feel it necessary, and in the best interest of the child (DOH 2007). This could be appropriate for Hannah as she is feeling guilty, and could find it difficult to go to the smoking cessation centre as she may feel people will judge her. As well as individual sessions, they offer group therapy (DOH 2007), this means that Hannah could be meeting new people in situations parallel to her own. By promoting and encouraging Hannah to attend group meetings, as a health professional we will be helping to provide an environment and support network that will help to facilitate her healthy choice. This could be furthered still with the links that are being established between the NHS services for pregnant smokers and the sure start programme (DOH 2007). This should ideally be providing Hannah not only with the opportunity to meet new people whilst she is in therapy for giving up smoking, but links with people and groups that can continue after the birth.

Hannah’s life revolves around smoking, with it being in her home, her work place and her social life. Ewles and Simnett (2003) discuss the importance of working at a national level, producing policies that will help to aid not only the individual, but society into making healthy choices. This concept is reflected in the Governments decision to pass The Health Act 2006 (DOH 2006). This piece of legislation means that by the end of 2007, the NHS and government departments, as well as all enclosed public places and work places will be smoke free (DOH 2006). For people in Hannah’s situation, where smoking has become a part of their day to day life, this will help to break the pattern they are in, helping them to stick with their lifestyle change until this becomes routine, everyday life.

Hannah has the right to continue smoking throughout the pregnancy, and should she decided to do this, it would invoke some complex ethical issues. As health professionals, Seedhouse (1998) states that we need to respect patient autonomy, however this is not the case if it is against the best interests of others. This poses difficulty in Hannah’s case, we should be respecting her decision, but by continuing this behaviour she will be putting the health of her child at risk. Beauchamp and Childress (1995, cited Stephenson 2004) identify the four ethical principals as beneficence, non-maleficence, respect for autonomy and justice. When educating and promoting health we can provide Hannah, and others in her situation, with beneficence and justice by presenting her with all the current information regarding the effects of smoking for her and the baby, but this must be done in a fair manor.

Meaning we can not over emphasise the dangers and risks, without mentioning the withdrawals she may suffer from quitting, and discussing how these may affect her moods and anxiety levels, and the possibility this may also have consequences for the baby. Beneficence is also given to Hannah by promoting the services available to her if she decides to take beneficial action (Naidoo and Wills 2002). By continuing to smoke Hannah is not avoiding the causation of harm, so in terms of non-maleficence, we as health professionals must then look at the possibility of harm minimisation (Naidoo and Wills 2002). In Hannah’s situation this may be promoting her to steadily cut down on cigarettes over a period of perhaps a month, with the intent to switch to NRT after this.

In this paper I have looked at the issue of smoking during pregnancy, using Hannah as an example. Firstly I discussed this matter in terms of its epidemiology, looking at statistics and figures for the south west, which is Hannah’s area. I also looked at the epidemiology of smoking more broadly throughout the UK, which highlighted just how many women find themselves in Hannah’s situation, and the possible factors that may count towards this occurring. I discussed health promotion models which may be suitable to aid education, and help to facilitate Hannah and other pregnant smokers towards taking a healthy path. I touched upon the Governments policies and actions which have been adopted to help people like Hannah choose to make a lifestyle change, and the push towards creating a healthy environment in which to sustain this. The ethical issues that arise from women smoking during pregnancy have been talked about, and possible ways to over come these examined.

Action on Smoking and Health [on-line] (2006) ‘Fact sheet 7, Smoking, Sex and Reproduction’ (22 May 2007).

British Medical Association [on-line] (2004) ‘Smoking and Reproductive Life’ (23 May 2007).

Department of Health [on-line] (2007) ‘Independence, choice and risk: a guide to best practice in supported decision making’ (23 May 2007).

Department of Health [on-line] (2007) ‘Local data on pregnant women smoking at the time of delivery’ (22 May 2007).

Department of Health [on-line] (2007) ‘NHS Stop Smoking Services and Nicotine
Replacement Therapy’ (25 May 2007).

Department of Health (1998) Smoking Kills: A White Paper on Tobacco: London, Stationary Office.

Department of Health [on-line] (2006) ‘The Health Act 2006’ http://www.opsi.gov.uk/acts/acts2006/ukpga_20060028_en.pdf (26 May 2007).

Erblich, J. Boyarsky, Y. Spring, B. Niaura, R. and Bovbjerg, D. (2003) A family history of smoking predicts heightened levels of stress-induced cigarette craving, Addiction, 98 (5) 657-644.

Ewles, L. and Simnett, I. (2003) Promoting Health: A Practical Guide. 5ed, London: Bailliere Tindall.

Fergusson, D. Horwood, J. Boden, J. and Jenkin, G. (2007) Childhood social disadvantage and smoking in adulthood: results of a 25-year longitudinal study, Addiction, 102 (3) 475-482.

The Information Centre, for Health and Social Care [on-line] (2007) ‘Infant Feeding Survey 2005’ http://www.ic.nhs.uk/pubs/breastfeed2005/ (22 May 2007).

Littlell, J, H. and Girvin, H. (2002) Stages of Change: A Critique, Behaviour Modification, 98 657-644

McNeil, A. (2004) Harm Reduction. British Medical Journal, 328 (7444) 885-887

Molyneux, A. (2004) Nicotine Replacement Therapy, British Medical Journal, 328 (7437) 454-456

Naidoo, J. and Wills, J. (2002) Health Promotion: Foundations for Practice. 2ed, London: Bailliere Tindall.

Nursing and Midwifery Council (2004) The Nursing and Midwifery Council Code of Conduct: Standards for Conduct, Performance and Ethics. London: NMC Publications.

Seedhouse, D. (1998) Ethics: The Heart of Healthcare. 2ed, Chichester: John Wiley and Sons.

Stephenson, A. (2004) A Textbook of General Practice. 2ed, London: Arnold

West, R. (2004) Assessment of dependence and motivation to stop smoking, British Medical Journal, 328 (7435) 338-339

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