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

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

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

4. 4Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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 rate25 % Netherlands:smoking rate26 % Sweden:smoking rate13 – 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)

5. 5Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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)

6. 6Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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)

7. 7Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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

8. 8Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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

9. 9Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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

10. 10Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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)

11. 11Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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)

12. 12Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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.)

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

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

15. 15Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 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.“

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

17. 17Wolfgang Hannöver, Institute for Medical Psychology, MINT Forum Sheffield 2011 MI for pregnant and postpartum women Crucial elements in behavior change: knowldegeEPE intentionmotivation ruler outcome expectanciesdecisional balance self-efficacyeffectiveness ruler emotional experienceOARS