Knowledge and attitudes regarding smoking during pregnancy

Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women

Predisposing factors: knowledge and attitudes regarding smoking during pregnancy

The average number of adverse outcomes that women thought could be increased by smoking was 9.2 of the 12 presented. Higher knowledge groupings were associated with completion of tertiary education (P = 0.048) and the belief that stopping smoking would be healthy for the baby (P = 0.024). Lower knowledge groupings were associated with others smoking inside the house (P = 0.010), the belief that having a small baby is a good thing or responding “don’t know” to this item (P = 0.026), and the belief that light smoking will not cause harm to an unborn baby (P = 0.016). No significant associations between individual knowledge items and smoking status were detected. Agreeing with the statement “if you are exposed to a lot of smoke from other people you may as well keep smoking yourself” was more common among Aboriginal participants (P = 0.03) and smokers (P = 0.005,).

Discussion

We found that having a smoking partner, having an Aboriginal partner and high levels of stress are associated with an increased risk of smoking during pregnancy for Aboriginal and Torres Strait Islander women. These social factors may be effective targets for smoking cessation interventions within this population. Due to shifted population norms among Aboriginal and Torres Strait Islander Australians, factors used to predict smoking in non-indigenous populations are not effective for Indigenous Australians. Socioeconomic status, age, parity and gravidity, have been identified as important predictors of continued smoking during pregnancy among non-indigenous groups. Although this study only had sufficient power to detect very large differences, it is feasible that the demographic characteristics and high population rate of smoking may differentiate Aboriginal and Torres Strait Islander women to such an extent that a different set of markers is required to predict smoking status.

A high level of general knowledge regarding the risks associated with smoking during pregnancy was apparent among both smokers and non-smokers. This is consistent with previous studies reporting good general knowledge but lack of awareness about specific risks for an unborn child and specific benefits of quitting. Attitudes regarding smoking and the health of the woman’s baby, however, contradicted the apparent level of knowledge — significantly more smokers than non-smokers believed that “if you are exposed to a lot of smoke from other people you might as well keep smoking yourself”.

This negativity towards quitting in the presence of passive smoke emphasises the significant role of the social environment in reinforcing smoking behaviour. A qualitative study of pregnant Indigenous women in Perth found that women commonly referred to smoking as normal, a stress release, a low health priority and a social experience, and commented that it was difficult to quit because they were surrounded by smoking from their family and household members. In the social context of high smoking rates and large numbers of adults per household, smoking may offer an opportunity to alleviate stress, acting as a social lubricant in “time-out, yarning, and sharing with others”. This provides a critical target for intervention in antenatal smoking; in order to help women to quit, it seems that consideration of and involvement with the social context in which women live are essential. However, although the social environment contains several barriers to changing smoking behaviour, the high prevalence of low socioeconomic status, young maternal age, and multiparity in the Indigenous Australian population decreases the statistical capacity for such factors to distinguish between smokers and non-smokers within this group.

The partner’s smoking status, number of smokers in the home, and ethnicity of the current partner were more important indicators of smoking behaviour than predisposing factors (knowledge and attitudes regarding antenatal smoking) or enabling factors. Although social factors have been shown to be predictive in other populations and are increasingly being recognised as key determinants of smoking and targets for intervention, the low socioeconomic status, multiple demographic risk factors, and high population smoking rates, may render these factors particularly salient among Aboriginal and Torres Strait Islander women.

Indigenous health literature is rife with examples of social, emotional and economic hardship. In this context, women may recognise the health risks of smoking for both themselves and their children, but rely on smoking as a coping tool and a “resource for caring for their children”. Women and Aboriginal health workers have commented on the stressors and difficult life circumstances that affect their attitudes to their own health, and stressful life events have been described as key barriers in attempts to quit smoking for Indigenous people. Rather than solely targeting smoking, it may be important to also address the sources of stress within the social environment, and equip women with coping strategies to better manage their circumstances.

There were several limitations of this study. First, it is possible that the social desirability of smoking cessation and presentation of the questions by a respected Torres Strait Islander health worker may have led to an overestimation of the knowledge level of the women. The use of a prompted list of items regarding the risks associated with smoking may not be the most appropriate approach to generating these data. Alternative techniques, such as asking women to nominate any risks known to them, may avoid the potential influence of the presented items. Second, fewer women visited the clinic for antenatal care during the recruitment period than expected, resulting in fewer than expected participants, hence the power of the study to detect differences in characteristics between smokers and non-smokers was reduced — the study only had adequate power to detect differences of about 23% between groups. Third, a large number of variables were examined, for which there was good rationale for inclusion, hence the large number of tests performed increased the possibility of a statistically significant association occurring by chance alone.

Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals. Although parallels do exist between Indigenous and non-Indigenous groups, key differences and low rates of success from previous smoking cessation intervention efforts in Indigenous communities suggest a need for specifically tailored intervention programs. The most appropriate approach to tackling the antenatal smoking issue should involve components targeted towards the individuals who influence and provide support to women. By involving women’s social networks in intervention efforts, there is potential to affect not only antenatal smoking rates, but smoking rates in the population overall, and challenge the normality and acceptability of smoking in the Aboriginal and Torres Strait Islander community.

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