Despite the smoking ban making it illegal to smoke in enclosed public places, introduced in England in 2007, smoking remains one of the single greatest causes of preventable illness and premature death in the UK. (1) There has been a reduction in rates of smoking, but a challenge remains in targeting high risk, hard to reach groups such as pregnant women.
Smoking during pregnancy, or even passive smoking, can cause serious damage to the health of both mother and baby. (2, 3) Indeed, smoking in pregnancy is one of the main causes of premature births and miscarriages. It has been shown that women who smoke during pregnancy have 1.5 to 3.5 times more chance of miscarriage when compared to non-smoking women. (4) Some women continue to smoke due to evidence that smokers have smaller babies. However, this is due to a lack of oxygen, which can severely affect the baby’s growth and development as well as cause numerous health problems in the future.
The implications of smoking during pregnancy go beyond affecting the mother and her baby, creating additional burden to an already overstretched national health service (NHS). It has been estimated that the increased cost to the NHS of smoking during pregnancy is £1,500 per smoker. (5) Thus, it has been recommended by the NHS Centre for reviews and dissemination that pregnant women are offered intensive advice and support to stop smoking. They specify that a combination of prenatal counselling, 10-minute face-to-face contact, and the provision of tailored written material, can double quit rates to about 15%. (6) Furthermore, a systematic review of best evidence, as conducted by the Cochrane Collaboration, indicates that the benefits of smoking cessation programs for pregnant women are great enough to recommend that they become routine within antenatal practice. (7)
The need for routine antenatal smoking cessation programmes is unquestionable. Research conducted by the British Market Research Bureau (BMRB) in 2005 demonstrated that 32% of mothers in England smoked during the 12-months before pregnancy and continued to smoke during pregnancy. (8) Although nearly half (49%) quit smoking before giving birth, three out of ten (30%) started smoking again less than a year after giving birth. It has been proposed that this is because women are usually motivated to stop smoking for the sake of the baby rather than for personal, long-term health reasons. Therefore, not only is there concern for the one in six (17%) women who continued to smoke throughout their pregnancy, there is also a need to promote long-term abstinence within public health initiatives. Of note, rates of quitting are generally lower among heavy smokers who are unmarried, on a low income, and poorly educated. (9) Therefore, meeting this public health challenge is likely to require highly targeted strategies in order to reach some of the most at risk groups of pregnant women.
Helping pregnant women to stop smoking is notoriously difficult due to the stigma attached to smoking while pregnant. The associated shame experienced by many women acts as a barrier to seeking help, as well as openly discussing smoking habits when questioned. This places pregnant women and their babies at increased vulnerability of complications resulting from continuing to smoke. It also increases the pressure on healthcare professionals to communicate the importance of smoking cessation to pregnant women, which can increase workload and also damage the relationship between pregnant women and their healthcare providers. Healthcare professionals are, understandably, keen to encourage pregnant women to stop smoking due to the known dangers; yet this can add to the shame experienced by the pregnant woman as well as be interpreted as confrontational, thus making them defensive.
There is a clear need for a public health intervention targeted not only at pregnant women, but also at their healthcare providers. The healthcare professional is key to educating pregnant women about the impact of smoking on themselves and their baby. Furthermore, it has been found that self-management initiatives related to health behaviours are unlikely to be sustained without the support and endorsement of health professionals. (10) However, there appears to be a skills gap that needs to be addressed in order for healthcare professionals to be able to approach this sensitive topic in a way that empowers the pregnant woman.
The challenges posed by pregnant women who continue to smoke require the establishment of an evidence-based programme of care that is integrated into the routine care delivered throughout their pregnancy. It is proposed that such an initiative would comprise an advanced development programme for the training of healthcare professionals in behaviour change techniques and, more specifically, in motivational interviewing skills. These skills are becoming more popular within the healthcare setting as they provide a brief psychotherapeutic communication style aimed at increasing the likelihood that a person will attempt to change unhealthy behaviours such as, in this case, smoking.
Motivational interviewing is a patient-centred style of communication designed to help people resolve any ambivalence they might have about changing an unhealthy behaviour, thus recognising that even unhealthy behaviours offer perceived benefits to the person carrying them out. It attempts to guide people towards personally choosing to change their unhealthy behaviour, rather than imposing expectations of change upon them, something which is frequently experienced by pregnant women who smoke. (11) This technique is based on the premise that if a person chooses to stop smoking themselves, they are more likely to be successful at any attempts to quit smoking.
The motivational interviewing technique is based on the transtheoretical model of behaviour change. (12) According to this theory, to achieve permanent change people go through a process of five distinct stages: pre-contemplation (i.e. not yet acknowledging an unhealthy behaviour that needs to be changed); contemplation (i.e. acknowledging the unhealthy behaviour, but not yet sure whether one is ready or wants to change); preparation (i.e. getting ready to change, perhaps setting a quit date); action (changing the unhealthy behaviour); and maintenance (i.e. remaining abstinent). In this sense, motivation is something that gradually grows and thus can be assisted by health professionals who are well placed to assess motivation to change. (13) Furthermore, with continued support, relapse prevention strategies can lower the likelihood of women returning to smoking which, as mentioned earlier, does frequently occur when smoking cessation is not motivated by personal reasons.
This model illustrates that approaching the issue of smoking during, for example, a stage where the woman has no intention or desire to change might become a confrontational consultation. However, motivational interviewing can be used to empower pregnant women in a way that encourages progression through the stages of change process. Motivational interviewing techniques that can assist with this include utilising open questions that convey the message that there are no preconceived views or judgments being made about the pregnant woman and her smoking habits. Closed questions, on the other hand, are often leading and thwart with expectation. With motivational interviewing, the primary goal is for the pregnant woman to be an active participant in the conversation and not just a passive recipient of information.
The four core principles to motivational interviewing are: expressing empathy (i.e. reflecting on and expressing an understanding of the pregnant woman’s perspective); developing discrepancy (i.e. exploring discrepancies between attitudes and beliefs and actual behaviour, e.g. believing smoking is unhealthy but continuing to smoke); rolling with resistance (i.e. understanding the barriers to change experienced by the pregnant woman, as well as any resistance to change); and supporting self-efficacy (i.e. working towards increasing the pregnant woman’s confidence in her ability to quit smoking and cope with any setbacks). (14)
These four core principles can be taught to health professionals to enhance their communication skills within health promotion initiatives such as one that targets pregnant women who smoke. Such skills are most often utilised in face-to-face consultations, but can also be used over the telephone; they are not intended for use within group settings. The application of motivational interviewing skills is diverse and yet can be taught to all health professionals over a period of 2-12 hours, usually via workshops. (15, 16)
The training does not have to be overly intensive and once this skill is adopted it can be delivered merely via conversation during regular consultations with the patient. A recommended programme would be to provide healthcare professionals who work with pregnant women with a 2-day training programme and to monitor the integration of these skills into practice. The advanced communication skills gained from the training, after practice, can become second nature and part of everyday practice. Indeed, motivational interviewing skills are transferrable to everyday face-to-face or telephone consultations. (17) Not only will these skills assist pregnant women in changing their behaviour, but they are also likely to prevent confrontations associated with the sensitive issues being addressed.
Evidence for the efficacy of motivational interviewing in helping pregnant women to stop smoking is strong. The most frequently adopted approach has been one in which smokers are provided with feedback, in a non-confrontational manner, intended to develop a discrepancy between their smoking behaviour and their personal goals. (18) Such a discrepancy is likely to lead to the uptake of any support that is offered to the pregnant woman as she commences attempts to quit smoking.
Karatay, Kublay and Emiroglu (2010) examined the effect of motivational interviewing on pregnant women (n=38) taking part in a smoking cessation intervention based on the transtheoretical model. (19) They found that 39.5% of the women were able to give up smoking, whilst 44.7% were able to reduce their rate of smoking by 60%. Rates of passive smoking pre-intervention, which were 86.8%, decreased to 55.3% post-intervention. Interestingly, mean self-efficacy scores increased substantially from 61.36 pre-intervention to 93.34 after the intervention. Not only had the motivational interviewing facilitated smoking cessation in some of the women, but it also reduced passive smoking and increased confidence in one’s ability to stop smoking and remain abstinent.
The important components of this intervention were reported to be the provision of information designed to raise awareness of the dangers of smoking, helping the woman identify and understand her reasons for smoking via a thoughts and feelings diary, and motivating the woman to consider any ambivalence she might have about quitting smoking. Other important components included helping the woman prepare herself for any quitting attempts by facilitating a decision regarding the method and date for quitting and putting in place methods to prevent passive smoking. It was also fundamental that sources of support were identified for helping the pregnant woman overcome any problems associated with giving up smoking so that she can succeed with her goal of being smoke-free.
In another study, where women (n=302) were randomly assigned to receive motivational interviewing or usual care, motivational interviewing was found to be relatively cost-effective. (20) The intervention comprised education about the impact of smoking on themselves and their baby, being helped to evaluate their smoking behaviour, and being taught skills that would increase their self-efficacy for smoking cessation and abstinence. The women were also provided with information on how to reduce passive smoking, as well as supported to set goals that would facilitate smoking cessation. At 6-months postpartum, for smoking cessation, motivational interviewing cost more for no additional benefit when compared to usual care. The motivational intervention did, however, prevent relapse more effectively than usual care, which in turn increased the cost-effectiveness of the initiative.
Some studies have reported low efficacy for using motivational interviewing with pregnant women who continue to smoke, but the majority of the evidence is in favour of the technique. (21) Even in the aforementioned study reporting low efficacy, fewer women in the motivational interviewing intervention reported that they were smoking more, when compared to the control group.
In order to deliver a training programme for health professionals involved in the care of pregnant women, organisational change will be necessary in order for new ways of working to be integrated into everyday practice. This will require the support of organisation Managers as well as commissioners who might fund a pilot study to test the effectiveness of training staff in motivational interviewing skills. In addition, input from the NHS, especially NHS Stop Smoking services, is likely to enhance the long-term effectiveness of such initiatives by acting as a resource for professionals to refer pregnant women for follow-up support.
The first step in the delivery of the initiative would be designing and conducting the initial training, which will be designed to develop communication skills in motivational interviewing during consultations. Importantly, however, according to a systematic review conducted by Soderlund et al. (2010), follow-up training or ‘refresher’ sessions might be necessary at appropriate intervals and this will need to be considered in terms of resource allocation. (22)
Velasquez et al. (2000) describe the process of training healthcare providers to use motivational interviewing with pregnant women, demonstrating that public health nurses and social workers are generally enthusiastic about attending training workshops and rate them as effective in preparing them to utilise motivational interviewing skills in practice. (23)
Hassel and von Rahden (2007), as part of a larger project, developed a 2-day programme of training in motivational interviewing for midwives. (24) The programme was designed around the stages of change model and focused on counselling skills that could be used to facilitate transition through the stages. This has also been referred to as ‘change talk’. (25) For example, techniques like the ‘Importance Ruler’ (used to assess how important smoking cessation or her baby’s health is to pregnant woman) were taught as a tool for progressing a conversation to the contemplation stage. It was found that this training provided the midwives with a greater array of practical tools they could use in their daily work. The skills that motivational interviewing practitioners need are those that are needed for enabling communication in all areas of healthcare: reflection, active listening and open-ended questioning. Therefore, the training is beneficial across all work the healthcare professional might be involved in.
Although motivational interviewing is more sophisticated than health promotion via the provision of written, it still incorporates information provision as a core element. However, the pregnant woman is coached and guided towards finding information and solutions for themselves. This provides the pregnant woman with options, which increases the effectiveness of motivational interviewing in eliciting change behaviour. Choice is seen as an empowering tool that can secure continued commitment to change (i.e. sustained smoking cessation).
A strong feature of skill development and mastery is that coaches continually learn and hone their practice from direct client experience. Reflection on practice in peer, expert and line managerial supervision is possible using motivational interviewing quality audit tools such. (26)
In measuring the effectiveness of this programme of training, a number of outcomes require assessing. The impact of the training on skills development and confidence in utilising these skills requires assessment via interviews or questionnaires with professionals who attended the training. Ideally, this needs to be done pre-training and post-training, as well as 6-12 months later in order to assess the long-term sustainability of any new ways of working.
Patient records will also require examination in order to track the rates of smoking in pregnant women, as well as the number of quit attempts (both successful and unsuccessful). Abstinence can be measured via self-report and tests for carbon monoxide. Furthermore, the monitoring of adverse events related to smoking could provide useful information on the clinical benefits of the programme.
Importantly, patient-reported outcome data can be collected via anonymous questionnaires eliciting information on service user satisfaction with the skills of healthcare workers, the content of consultations, and the usefulness of the support provided for issues such as smoking cessation.
Overall, the design and delivery of a motivational interviewing training programme for healthcare professionals requires a multidisciplinary approach. In turn, the evaluation of the outcomes of the programme requires a whole-systems approach that takes into consideration both objective and subjective short- and long-term benefits to tackling the public health challenge of smoking in pregnancy.