individuals pictured in cigarette advertisements. The latter are
seen as attractive (by 69 percent), enjoying themselves (by 66
percent), well dressed (by 66 percent), sexy (by 54 percent),
young (by 50 percent), and healthy (by 49 percent). There is no
comparable data on how girl nonsmokers or young adult women
view advertising (216).

Thus, advertisers have been successful in creating a sense of
mystery, sophistication, and power around the behavior of
smoking. Although smoking was once frowned upon for women,
people now respond less negatively to a woman smoking (16).
There is evidence that, for some women, smoking is linked with
attitudes and behaviors that comprise a socially valued and
successful self-image, and that giving up smoking is a threat to
that image (123). ,

A majority of former smokers and nonsmokers of both sexes
in the 1975 Adult Use of Tobacco Survey (194) agreed with the
statement, “Cigarette advertising should be stopped com-
pletely.” The percentages for men were 56.9 percent for
nonsmokers and 56.4 percent for former smokers, and for
women, 68.2 percent for nonsmokers, and 62.5 percent for
former smokers. However, only 42.6 percent of male smokers
and 42.5 percent of females smokers agreed with the statement.
It appears that adult smokers value cigarette advertisements,
but why they do—whether for information about brand charac-
terization and availability, identification with the image por-
trayed, or some other reason—is not known. Fishbein concluded
that cigarette advertising influences the decision to smoke. as
well as the choice of brand. Furthermore, he points out that
cigarette advertising may serve as a discriminative stimulus for
smoking behavior. Advertising can influence the initiation of
smoking, the choice of brands smoked, and the level of consump-
tion. Commenting that the tobacco industry asserts that adver-
tising serves only to influence brand choice and not initiation or:
consumption, Fishbein maintains that it is somewhat unrealis-
tic to assume that an advertisement which can do one of these
things is not also capable of doing the other. While additional
research on the effects of cigarette advertising is clearly neces-
sary, this review suggests that cigarette advertising does affect
cigarette consumption (63).

Restrictions have now been placed on advertising in many
countries in the world, including the United States. There is no
uniform agreement that the ban on televised cigarette advertis-
ing in the United States and the United Kingdom significantly
reduced consumption. However, it is generally believed that
each action of this sort—including the U.S. Surgeon General’s
Reports and the Reports of the Royal College of Physicians, as

326
well as other smoking control measures such as taxation and

legislation—has a cumulative effect on per capita consumption
(8,142,202),

THE FAILURE TO DISSEMINATE INFORMATION

Many of the critical evaluations of public health campaigns
conveying anti-smoking information maintain that little at-
titudinal or behavioral change is ever effected (188). Fishbein
(63) argues that there is insufficient information describing the
complex relationships between cigarette smoking behavior and
beliefs, attitudes, and intentions to make this conclusion. He
further maintains that it is necessary to know to what extent
decisions regarding initiation, reduction, increase or cessation
are under attitudinal (individual, personal) or normative
(society-influenced) control. The importance of personalizing
the health message, and the failure of the public to personalize ~
the health messages that they have received is emphasized. For
example, over 80 percent of smokers agree with the statement
that smoking is hazardous to health. However, on the question,
“Are you in any way concerned about the possible effects of
cigarette smoking on your health?” only 25 percent of current
smokers in the 1975 NCSH survey stated that they were “very
concerned,” another 22.6 percent were “fairly concerned,” 18.9
percent were “only slightly concerned,” and a final 31.9 percent
were “not concerned” (194). Fishbein maintains that the public
is not effectively informed about the general danger to health
posed by smoking and is even less informed about the connec-
tion with specific diseases. He concludes that the content of an
effective message is fourfold: that continued smoking leads to
negative outcomes; that stopping smoking leads to positive out-
comes; that personal relevance must be established; and that
normative influences must be appealed to by maintaining that
significant others think an individual should quit.

Stress at Work

A general model of stress at work (38) is worthy of considera-
tion. Examination of the sources of stress at work (Figure 2)
reveals a number of items that are especially salient for women.
Discrimination against women in employment, role conflict, au-
thority problems, inequity in promotions, exclusion from
decision-making processes and the “old boys” network have
been frequently discussed (68). Individual characteristics may
be considered from a gender viewpoint as well; for example,
some types of psychological disorders, such as anxiety and de-

327
8a8

Sources of Stress
At Work

Individual
Characteristics

 

Intrinsic to job:

Poor physical working conditions
Work overload

Time pressures

Physical danger, etc.

   

The individual:

 

Role in organization:

Role ambiguity

Role conflict
Responsibility for people
Conflicts re organizational
boundaries (internal

and external), etc.

 
   

  

Level of
anxiety

  
  
 

  
 
 

Level of
neuroticism

 

Tolerance for

 

Career development:
Overpromotion
Underpromotion

Lack of job security
Thwarted ambition, etc.

    
 

 

ambiguity

Type A behavioural
pattern

    

 

Relationships at work:

Poor relations with boss,
subordinates, or colleagues
Difficulties in delegating
responsibility, etc.

 

     

  

Extra-organizational
sources of stress:

 

Organizational structure and
climate:

Little or no participation

in decision-making
Restrictions on behaviour
(budgets, etc.)

 

Office politics

J tees of effective consultation, etc.

    

  

Family problems
Life crises
Financial difficulties, etc.

    

 

FIGURE 2.—A model of stress at work

Symptoms of Occupational Disease
ill Health

 

Diastolic blood pressure

 
     
   
 
   

Coronary
heart
disease

Cholesterol level
Heart rate
Smoking

Depressive mood

  

Mental
il
health

 
   

Escapist drinking

Job dissatisfaction

 

Reduced aspiration, etc.

 
pression, are more prevalent among women than men (48,68).
The Type A behavior pattern, which is associated with male
cardiovascular disease, has been shown to be unrelated to sex
once socioeconomic status is taken into consideration (172).

An additional set of stressors originates in the extraorganiza-
tional environment. A prospective study of the relationship of
employment status and employment-related behaviors to coro-
nary heart disease (CHD) incidence was conducted by Haynes
and Feinleib (91). Working women scored higher on scales
measuring daily stress, marital dissatisfaction, and aging wor-
ries than men. They were also less likely to display overt anger
than either homemakers or men. While incidence rates of coro-
nary heart disease in working women were not significantly
higher than in homemakers, an excess risk of CHD was iden-
tified among women who were employed in clerical jobs and had
children. The risk factors for CHD in this group included family
responsibilities, suppressed hostility, a nonsupportive super-
visor, and low job mobility over the preceding 10-year period.

Smoking Habits of Health Professionals

There are relatively few studies available which present
gender-specific smoking rates in various professions. Health
professionals were selected for analysis because they were more
likely to be aware of the health consequences of smoking than

the general public; this group has also been studied more exten-
sively.

PHYSICIANS

The smoking habits of male and female physicians in five
nations are presented in Table 15. Smoking rates in the general
population are provided for comparison when supplied by the
authors. No breakdowns by gender are available for the United
States. Separate estimates of smoking rate in a small group of
women physicians age 36 to 46 at the time of survey (205) and in
a large sample of predominantly male (93 percent) physicians
(195) are listed in the table. In addition, the wives of 3,990
physicians were queried about their own smoking habits and
those of their husbands; no information is provided on the
occupations of these women (77).

Examination of the table shows that smoking rates of
physicians, both male and female, tend to be much lower than
general population rates. The only exception is the higher rate
of current smokers among female physicians in Finland (200).
The percentage of current smokers among the sample of U.S.
female physicians is higher than that reported in other

3829
& TABLE 15.—Smoking habits of male and female physicians in selected countries

0

 

 

 

 

 

 

 

 

 

Percent Smokers
Pop. Pop. Pop.
Author Country Number Never Est. Current Est. Former Est.
1. Bourke, et al., 1972 (22) Ireland M 1359 17.9 —  19.7* 48.5 — 67.6" 33.6 — 12.7%
F 221 51.5 53.9 26.7 — 38.6* 22.2 — 7.5*
2. Vuori et al., 1971 (200) Finland M 843 38 34 60 27
F 66 26 20 8
3. Wilhelmsen & Faith-Ell, 1974 (210) Sweden ? 33 38 29
54 27 19
4. Aaro et al., 1977 (1) Norway M_~ 740 35.3 —  53* 3nO 27'*
F 398 21.7 — 36* 38: — 20'*
5. Westling-Wikstrand et al., 1970 (205) USA F 81 42 35.8 13.6
6. Greenwald et al., 1971? (77) USA M 3990 325 24 433
F 3990 35° 36 273
7. USDHEW, 1976 (195) USA M 36574 21 39 64! 43}
34}

 

*Significant difference between percentages paired by (—).

former smoker

‘Stopping rate = ever smoker

2Sample consisted of physicians and their wives whose profession was undefined.

3Percentages estimated from graph, not specified in text.

4Approximate total of M and F, estimated to be 93% male.
countries and approaches the rates in the general population
(205). Prevalence of smoking has a strong relation to
demographic variables such as profession, income, and
education. We would expect physicians to be in the highest
category on each of these variables and, therefore, to have
lower prevalence rates. Therefore, it would be relevant to
examine the cross-tabulations for smoking prevalence by
socioeconomic status, according to sex.

According to the three studies providing comparative data,
both female and male physicians are quitting at rates higher
than the general population. The percentage of former smokers
among female physicians, and estimates of quit rate, are lower
than among male physicians in all but one of the studies listed.
This trend may represent a time lag in the smoking behavior of
women as compared to that of men, or there may be a lower quit
rate among women physicians.

In two studies, female physicians smoked more cigarettes per
day than women in the general population (1,22). In contrast,
wives of physicians smoked fewer cigarettes on the average
than their husbands (77). A greater percentage of the wives of
physicians than physicians themselves were smokers in every
age group except the oldest. The percentage of current smokers
appeared to be inversely related to age in the group of wives,
but virtually stable across age for the physician-husbands.
Husbands and wives tended to have similar smoking habits.

Based on a small sample of women graduates of a single U.S.
medical school, Westling-Wikstrand, et al. (205) reported that
58.8 percent of the current smokers belonged to the category
“professor” (academic appointment of assistant professor or
above, with or without board attainment) when ranked on pro-
fessional attainment. The other categories were “boards” (spe-
cialty board certification but not professional appointments),
“no boards” (in practice without board certification or profes-
sional appointment), and “not in practice.” The “professor”
group was characterized by greater likelihood of being single
and having fewer “habits of nervous tension.” Compared to
other groups, this group had the lowest depression scores, aver-
age anger scores, and the highest anxiety scores. The authors
comment that this group of women was the most similar to their
male colleagues. They may also have experienced fewer prob-
lems with ambivalence about sex roles, self-image, or conflict
over aggressive behavioral patterns. The presence of the high
anxiety scale, however, casts some doubt on this generalization.

Women in U.S. medical schools are subjected to significant
psychological pressures and often experience emotional prob-
lems and lack of confidence about achieving the goal of gradua-

331
tion (205). Female physicians also experience significant role
conflict (19).

The relevance of indices of stress to smoking patterns is again
one of inference. If smoking serves as a coping mechanism—a
means of reducing negative affect—then it is understandable
that female physicians, or any other professional with elevated
stress levels, would have higher current smoking rates than the
general populace. It is also understandable that they might ex-
perience more difficulty in quitting.

PSYCHOLOGISTS

A survey of psychologists in California state universities and
colleges found that female psychologists were much more likely
to smoke than their male colleagues (46). The rate of smoking
was slightly higher than in male health professionals, and ap-
proximately the same for female psychologists (38 percent) and
nurses (195) (see Table 16).

This smoking rate is significantly above the rate among pro-
fessional women in general (25.6 percent) and was due to lower
cessation rates among psychologists rather than higher initia-
tion rates. The most common reasons given for smoking are the
stress of work or school, and personal stress. Frieze, et al. state
that professional women have to exhibit “male-like” character-
istics in order to survive in their jobs, but that these character-
istics are often met with criticism and hostility (67). Thus, social
and occupational demands are at odds with each other. Fur-
thermore, there is evidence that female psychologists face very
real sex discrimination in the evaluation of their work (67).

Dicken and Bryson (46) report a high degree of power fan-
tasies among female psychologists who smoke. This supports
Fisher’s finding that female smokers in general seem preoc-
cupied with the issue of power (64). He speculates that cigar-
ettes are used defensively against feelings of powerlessness,
weakness, and inferiority.

Elevated suicide rates are another correlate to the evidence
of excessive stress and difficulty in coping experienced by some
female professionals. These higher rates, compared with the
general female population, have been observed among women
psychologists, chemists, and physicians (124,164). Factors such
as ambivalence about success, role conflict and marginality
were offered as dynamics. However, it is not possible to deter-
mine whether these higher suicide rates are due to the self-
selection of suicide-prone women into these and possibly other
professions, or to the difficulties encountered in professional
training and practice (or to an interaction of both).

332
NURSES

A number of studies have shown a higher rate of smoking
among nurses than in the general female population in the
United States. The most recent assessment of nurses’ smoking
behavior was conducted in 1975 (199). In Table 16, smoking
habits of nurses are compared with those of adult U.S. women
and other groups of health professionals.

Between 1969 and 1975, the proportion of nurses who were
current smokers rose from 37 to 39 percent. Every other cate-
gory of health professional (physician, dentist, and pharmacist)
had substantially reduced smoking rates. The membership of
these three professions is predominantly male and current
smoking rates vary from 21 to 28 percent. If one examines quit
rates in 1975 among the four categories of health professionals,
it is clear that the majority of physicians, dentists, and pharma-
cists who ever smoked cigarettes have quit: 64, 61, and 55 per-
cent respectively. Among nurses, only 36 percent have quit,
which does, however, compare favorably with adult women (34
percent) and working women (30 percent) (199).

Noll surveyed smoking behaviors of nurses by work setting
(see Table 17) (135). The overall percentage of current smokers
in this survey was 37 percent, compared to a national average
(for 1966) of 33.7 percent in women. There was a smaller per-
centage of never smokers (41.3 percent) among nurses in that
survey than among the female population (56.8 percent),
suggesting a higher quitting rate at that time as well. From
Table 17 it appears that there is no selective recruitment into
the various nursing specialties; the proportion of never smokers
is fairly equal across work settings. Differences do appear, how-
ever, in the proportion of current smokers according to work
setting. Highest rates of smoking are found in psychiatric and
pediatric settings, and lowest rates in the four categories con-
nected to education and community involvement: nursing edu-
cation, working in the community, elementary or high school
nursing, and working in a doctor’s office.

In Great Britain, only 26 percent of maternity nurses smoked
regularly, compared to 37 percent of those in general nursing
(106). In the United Kingdom, approximately the same propor-
tion of nurses smoke as women in the general population —44
percent (106,154).

Knopf Elkind reports differences in smoking among different
types of ward nursing staff. Trained nurses had 41 percent cur-
rent smokers, learners had 28 percent, nursery nurses had 14
percent, and auxiliaries had 61 percent current smokers (106).

Lampman reported a similar excess of smokers among nurses

333
ree

TABLE 16.— Percentages of cigarette smokers (S), former smokers (FS), and ever smokers (ES) and cessation
ratio (FS/ES) among psychologists, nurses, and other selected health professionals

 

 

Sample N Ss FS ES FS/ES
Male and predominantly male samples
CSUC male psychologists 258 28 35 62 55
Eminent experimental psychologists— 90% male
(Lawton and Goldman, 1961) q2 53 11 64 17
Psychiatrists —% male not reported
(Tamarin and Eisinger, 1972) 309 42 27 69 39
American Public Health Association male members
(Eyres, 1973) 3,569 21 40 61 66
Physicians—93% male (USPHS, 1977) 8,657 21 42 63 67
U.S. adult males (USDHEW, 1976) 5,702 39 29 69 42
Female and predominantly female samples
CSUC female psychologists 86 38 19 57 33
American Public Health Association female members
(Eyres, 1973) 1,973 31 31 62 50
Nurses— 98% female (USPHS, 1977) 2,429 39 22 61 36
U.S. adult females (USDHEW, 1976) 6,327 29 14 43 33

 

NOTE: CSUC = California State University and Colleges.
SOURCE: Dicken, C. (46).
TABLE 17.— Cigarette smoking status by work setting for nurses

 

 

 

(percent)
Cigarette Smoking Status Total*
Work Setting Current Former Never Percent N
Surgical Units 41.2 19.4 39.4 100.0 529
Medical Units 37.8 18.2 43.9 99.9 476
Operating, Labor, Delivery
Emergency Room 39.8 15.2 45.0 100.0 485
Maternity Unit 36.2 17.2 46.6 100.0 197
Pediatrics Unit or Setting 46.6 8.8 44.6 100.0 80
Psychiatric Unit or Setting 49.9 18.2 32.0 100.1 135
Nursing Education Setting 24.6 26.8 48.7 100.1 90
In the Community 26.1 33.4 40.6 100.1 264
Elementary or High School 27.5 36.4 36.1 100.0 217
Doctor’s Office 24.2 33.8 41.9 99.9 338
Out-Patient Clinic 42.5 15.1 42.5 100.1 113
Other and Mixed 41.3 18.4 40.3 100.0 1,078

 

*Total N = 6,012
SOURCE: Noll, C.E. (135).

aides (95.2 percent female) in a large metropolitan hospital in
the United States (110). Fifty-two percent of that group smoked,
compared with 36 percent of the medical nurses (99.3 percent
female) and 40 percent of the student nurses (95.6 percent
female). This survey was aimed at identifying smoking within
the hospital. Thus, true prevalence in this sample can only be
higher.

Compared to other female health professionals (see Table 16)
in the United States, nurses’ quit rates are above some (psy-
chologists, U.S. adult women) and below others (American Pub-
lic Health Association female members). Knopf Elkind points
out that in the British population other female-dominated pro-
fessions, such as primary school teachers, health visitors and
domiciliary midwives, have noticeably lower rates of smoking
than hospital nurses (106). Entry into the profession of nursing
is associated with taking up daily smoking but the degree of
occupational stress in a population of 300 British student
nurses was not different for smokers and nonsmokers (92). This
finding does not rule out the use of smoking as a stress-
reduction mechanism, however.

Other factors which might contribute to a high smoking rate
among nurses are work overload and frustration in professional
relationships with physicians.

Knowledge of health consequences of smoking is high among
nurses, but it has been shown that student nurses are less well-
informed than medical students (154). Nurses who quit smoking

335
do cite protection of future health as a major reason (75,92).
Nurses who smoke are less likely than nonsmokers to agree that
not smoking is a preventive measure against cancer (106). Simi-
lar refusal to acknowledge health risks of smoking is found
among smokers in the general population (194). Whether this
represents a real lack of knowledge or a method of reducing
cognitive dissonance through denial is unknown. The problem is
particularly critical for nurses (and other health professionals)
since they serve both as exemplars and as providers of informa-
tion (106).

The Pregnant Smoker—a Special Target

The pregnant woman is in a unique life situation. Every sub-
stance she ingests and every behavior that she manifests can
affect the present and future health status of the fetus she is
carrying. If she smokes, the nicotine, carbon monoxide, and hy-
drogen cyanide which she inhales all cross the placental barrier
and enter the bloodstream of the fetus. The risk factors for both
mother and fetus have been extensively reviewed elsewhere in
this volume as well as in previous reports from the Surgeon
General (198). (See also Pregnancy and Infant Health in Part II
of this Report).

It is estimated that between one-quarter and one-third of
pregnant smokers quit smoking for the duration of pregnancy
and that another third cut down.

This section reviews the current literature on sources of in-
formation available to the pregnant smoker, summarizes avail-
able data on prevalence of current smoking and smoking cessa-
tion during pregnancy, and discusses the problem of cessation
from a behavioral viewpoint.

SOURCES OF INFORMATION

The same classes of information discussed in the previous sec-
tion are available to the pregnant smoker. How the pregnant
smoker uses these sources and her degree of confidence in the
information provided seems to be a function of socioeconomic
status and parity. Information is distributed through health
professionals (primarily physicians and nurses), peers and fam-
ily, community resources, and the media.

Women in lower socioeconomic classes tend to rely more on
lay referral systems, such as peers and family, than upon mass |
media or medical sources (10,74). Personal transmission of in-
formation seems to be more highly valued and readily adhered
to (71). Middle and upper class women are more likely to utilize

386°
impersonal sources such as mass media and physician-supplied
information (74).

In one study of predominantly working class British women,
the mode of exposure to smoking information ranked as follows:
84 percent had seen it on television; 65 percent were told by
family or friends; 52 percent had seen posters and leaflets; 37
percent had been told by husbands; 34 percent used books and
magazines; and 25 percent had been told by a medical source (16
percent from a doctor, and 9 percent from a nurse) (11). The
authors comment that television, posters, and leaflets are in-
adequate for the delivery of statistical information; books,
which are better sources, were used much less than these other
sources. Baric and MacArthur present a discussion of health
norms in pregnancy (10). Seventy-nine percent of the sample
were aware of some norm relating to smoking in pregnancy: 39
percent thought they were expected not to smoke at all, and an
additional 40 percent thought they were expected to reduce
their smoking. All of the women could name at least one source
of information; 98 percent had been exposed to mass-media
messages to quit smoking. Smoking seemed to be undergoing a
change in norm status, from generality to specificity, i.e., from
being a general health menace to one with specific conse-
quences, such as a threat to the health of the baby.

The issue of normative behavior in smoking and personaliza-
tion of message should be crucial to informational campaigns,
according to Fishbein’s theory (63). Social support from a spouse
should also be critical, as would be involvement of significant
others.

Women about to have their first baby are more likely to be-
lieve educational materials than multiparous women (11,50).
This finding suggests that different modes of intervention or
different emphases should be developed for primiparous and
multiparous women.

Physician Advice

The physician represents one of the most knowledgeable fig-
ures the pregnant woman will encounter as a source of informa-
tion. Consequently, estimates of the frequency with which the
physician delivers advice on smoking are of importance.

Three such estimates are available from national samples in
the United States. In the first study, conducted in the mid-
1960s, 37 percent of physicians reported that they advised all or
almost all (95 to 100 percent) of their pregnant patients to quit
smoking or cut down sharply. Obstetricians were more likely to
deliver such advice to pregnant patients (49 percent) than were
physicians in general practice (38 percent) (76).

337
 

YJ Major n= 5401

 
  

PS] Contributing Cause
ua Association
No Association
100 F- 93.2 90.4 92.6 =

  
  

ox

Sd
bo
52

 
   

     

 

o,
2

 
     
   

   
  

 

 

5 80r oe s 7
5 60F y Y
a Y
Y
40 GZ
Y
20 Y
0 AES
Neonatal Coronary Chronic Pulmonary = Lung
Death Artery Bronchitis Emphysema Cancer
Disease

FIGURE 3.—Beliefs of OB-GYN specialists about the association
of maternal smoking with neonatal death and other

selected diseases
SOURCE: Danaher, B.G. (40).

The Physician Advice Survey conducted by the Center for
Disease Control examined the beliefs and behavior of physi-
cians specializing in Obstetrics and Gynecology (OB-GYN) in
the United States (40). The OB-GYN specialty practice includes
preventive medical care in the form of specific suggestions re-
garding hygiene and family planning and, during pregnancy,
active participation in directing perinatal care (40). The beliefs
of OB-GYN specialists about the relationship between maternal
smoking and neonatal death are presented in Figure 3, along
with their belief about some of the more common diseases as-
sociated with smoking. Because neonatal death can result from
a great many factors, the attribution of causality is somewhat
lower than for the other conditions represented. However, it is
notable that 23.6 percent of the physicians deny the existence of
any relationship. Congruent with the estimate from the 1960s,
45.3 percent of OB-GYN specialists in this survey claimed to
instruct all or almost all of their patients to quit or cut down on
smoking (see Figure 4). Another 13.1 percent delivered such ad-
vice to most or many (65 to 95 percent). A noticeably smaller
fraction of physicians who are current smokers deliver this
message than ex-smokers or nonsmokers.

The 1975 Survey of Adult Use of Tobacco, sponsored by the
National Clearinghouse on Smoking and Health, included a

338
70

NjAdvise All + Almost All Patients
60 Most + Many
EFew + None

50 45.3

40

Percent

30

20

10

   

0
Total Current Former Non-
(n = 3208) Smokers Smokers Smokers
(n =622) (n = 1187) (n = 1404)

FIGURE 4.— Percentage of patients advised to quit or cut down
their smoking by the smoking behavior of the advis-
ing obstetrician-gynecologist

SOURCE: Danaher, B.G. (40).

questionnaire directed at smoking habits in pregnant women. A
preliminary analysis of the results has been made (89). Out of
12,029 respondents interviewed in 1975, a total of 1,225 women
(814 current smokers and 411 former smokers) were adminis-
tered questions about their smoking habits during pregnancy.

Each of the 983 respondents (664 current smokers and 319
former smokers) who had ever been pregnant was asked
whether her doctor suggested that she quit smoking or cut
down during her last pregnancy. Table 18 displays the results
by year of last pregnancy. The percentage of women reporting
such advice from their doctors rose steadily. Only 14.6 percent of
women who had last been pregnant from 1965 to 1969 claimed to
have been advised by their doctor either to stop or cut down;
23.7 percent of women last pregnant from 1970 to 1975 remem-
bered such advice. These estimates are considerably smaller
than those supplied by physicians themselves (40,76). There are
several possible explanations for the discrepancy: the women
were reporting retrospectively, and memory may have been dis-
torted; a selective under-reporting of advice may have occurred;
or the populations of physicians and patients may be entirely
nonoverlapping. Retrospective data have been shown to be un-
reliable in one pregnancy study (49). Unfortunately, sample
sizes were too small to provide reliable estimates of the per-

339
TABLE 18.—Distribution of responses of current former
smokers who were ever pregnant to the question
“Did your doctor suggest that you cut down or stop
smoking cigarettes during your last pregnancy?”

 

Percent by Year of Last Pregnancy
(Prior to (1965- (1970- (1965-

 

 

 

Physician's Advice 1965) 69) 75) 75)
Quit smoking 5.6 6.2 10.8 9.3
Cut down smoking 5.7 8.4 12.9 11.4
No advice given 70.5 64.1 65.6 65.1
Not smoking at the time 16.4 20.6 9.1 12.9
Had no doctor 0.5 0 0.2 0.1
Don’t know or no answer 1.3 0.8 1.3 0.9
Number of respondents 466 215 291 506

 

SOURCE: National Clearinghouse for Smoking and Health (194).

centage of women who followed the advice of a physician to stop
smoking during pregnancy. Such data might have yielded an
estimate of the effectiveness of such advice.

In sum, over 50 percent of physicians claim to advise their
pregnant patients to eliminate or sharply curtail their smoking
during pregnancy, but a much smaller percentage of pregnant
women recall such advice.

PREVALENCE OF SMOKING AND QUITTING DURING
PREGNANCY

The prevalence of smoking in pregnant women (before special
cessation efforts) should be roughly equivalent to the preva-
lence of smoking in the female population in the same age
range, corrected for socioeconomic status. Ten studies con-
ducted in developed countries, reported between 1971 and 1973,
show a range from 23.4 percent to 47.6 percent in prevalence of
tobacco use (145). The median rate is 42.75 percent smokers for
the entire sample. A survey (conducted during the course of the
pregnancy) of 9,553 pregnant women who represent a cross sec-
tion of the general population in the Riverside-San Bernadino-
Ontario (California) area was recently completed (108). Prelimi-
nary results indicate that 44.5 percent of all women surveyed
either continued to smoke during pregnancy or had smoked be-
fore, but not during, this pregnancy. Since the precise time of
cessation is not clear, a more conservative estimate is that 33.3
percent of women continued to smoke for the duration of their
pregnancy. This estimate is well within the range of those de-
rived from the Population Report analysis (145).

340
There is a paucity of race-specific information on smoking
prevalence during pregnancy. Niswander and Gordon (134), ina
study encompassing 14 U.S. cities, reported greater prevalence
of smoking among white than black women (53.65 percent vs.
41.85 percent, respectively). This is a high estimate and reversal
of the prevalence rates presented in Table 7. The finding is simi-
lar to the previously presented data, in that white women
smoked more cigarettes per day than black women: only 3.3
percent of black women smokers consume a pack a day or more,
compared to 13.4 percent of white women in this study. Smoking
is slightly less prevalent in black than in white women in the
sample of Kuzma and Phillips (108): 57.3 percent of black women
and 53.3 percent of white women have never smoked. For His-
panic women, the percentage is somewhat higher, 61.9 percent
never-smokers. Table 19 summarizes the results of 11 studies
reporting rates of discontinuing smoking during pregnancy.
The overall rate of cessation among regular smokers ranges
from 0.9 percent to 35 percent, which is the figure most often
anecdotally cited. The median is closer to 20 percent.

Only one study provides ethnic data on smoking cessation
during pregnancy (108). In this study, it should be remembered,
stopped smokers are women who smoked prior to, but not dur-
ing the pregnancy, so that quitting may not have been
pregnancy-specific. Rates are very similar for white, black and
Hispanic women: 24.5 percent, 24.9 percent and 28.7 percent,
respectively, were stopped smokers in this study.

Even acute abstinence from cigarette smoking may be of
value, if it occurs immediately prior to giving birth. In the
United Kingdom, women are often admitted as early as 48 hours
before elective delivery; abstaining from smoking for that
period of time was found to result in a net percent increase in
available oxygen as COHb was excreted (42). Such a temporary
benefit may actually be critical under acutely stressful condi-
tions, and where there is chronic placental insufficiency.

Cutting down on smoking during pregnancy would appear to
be better than no change in behavior, especially for those ad-
verse effects upon the fetus which show a dose-response rela-
tionship. However, cutting down on number of cigarettes does
not always imply a reduction in delivered dose of nicotine or
other tobacco smoke constituents (79,80). When smoking behav-
ior was measured over the course of pregnancy in regular
smokers (5 to 30 cigarettes per day for at least 5 years), a de-
crease in number of puffs per cigarette occurred as pregnancy
progressed (6). Like puffing rate, the COHb concentration also
decreased over time in pregnancy. However, in these subjects
there was no significant change in nicotine dose extracted from

341
= TABLE 19.—Percentage of current smokers who altered smoking behavior during pregnancy

 

Change in Smoking Habit— Percent of Women

 

 

 

 

 

 

 

 

 

 

Cut
Quit Down No Miscellaneous,
Author and Date N Quit Temporarily Only Increased Change or Comment
1. Kullander & Kallen, 1971 (107) 2,806 0.9 1.3 97.3 +0.5 Initiated
2. Andrews & McGarry, 1972 (4) 6,733 14.7 Maternities only
3. Butler et al., 1972 (29) 841 18.4 Quit by end of 4th month
4. Schwartz et al., 1972 (171) 1,188 31.0 10.0
5. Baric et al., 1976! 134 14.9 3.0 82.1 Quit by 1st ante-natal visit
6. Graham, 1976 (74) 50 33.3* 33.3* 33.3 *1/3 quit or cut down;
1/3 cut down temporarily
7. Baric & MacArthur, 1977! (10) 133 22.5 6.0 33.1 5.3 26.3 +6.8 reduced temporarily
8. Donovan, 1977 (49) 959 12.5 5.6
9. Yankelovich et al., 1977 (216) ? 35.0 32.0
hE

TABLE 19.—Percentage of current smokers who altered smoking behavior during pregnancy—Continued

 

Change in Smoking Habit— Percent of Women

 

 

Cut
Quit Down No Miscellaneous,
Author and Date N Quit Temporarily Only Increased Change or Comment

10. Harris, 1979 (89) 4092 26.5 24.8 7.9 36.9 +3.9 changed brand or
switched to filter cigarettes
82.2 of quitters resumed
smoking after delivery

11. Kuzma & Phillips, 1979 (108) 4,249 25.1 13.4 of quit smokers were

again smoking at 1-5 mo.
post-delivery

 

NOTE: !These two studies may be composed of overlapping samples.
2Of the 506 women in the NCSH survey whose last pregnancy occurred during 1965-75, 409 reported smoking either before or
during pregnancy.
’Percent who smoked prior to, but not during this pregnancy, calculated as part of smoker sample.
the cigarette over the duration of the pregnancy. Some alter-
ation in puffing pattern, presumably in inhalation, produced
the compensation. Thus, caution must be exercised in the in-
terpretation of “cutting down.”

There is even less information available on the percentage of
quit-smokers who return to smoking after delivery. Table 19
provides two extremely divergent estimates: 82.2 percent (89)
and 13.4 percent (108). Because we are dealing with relatively
small sample sizes, the reliability of such data is not very high.
Much more information must be accumulated before any firm
statements about recidivism can be made. Women who quit dur-
ing pregnancy have an excellent opportunity to change a behav-
ior for life, with benefits both to themselves and to their chil-
dren (see Recommendations).

PSYCHOSOCIAL FACTORS IN QUITTING

Health reasons, primarily centering around preventing harm
to the fetus, are most often given as reasons for quitting. Yan-
kelovich, et al. (216) report that 62 percent of young women
smokers believe that smoking can harm the fetus and norms
against smoking have been discussed (10). The sickness experi-
enced as a part of pregnancy can also be a reason to give up
smoking (11). It has also been reported that women who smoke
before pregnancy show a significantly increased incidence of
appetite cravings and aversions, which may be associated with
quitting (41).

A closely related aspect of maternal health is weight gain.
Preventing excessive weight gain has even been given as a rea-
son to continue smoking during pregnancy (50). Baric and
MacArthur included control of weight gain as a norm during
pregnancy; 24 percent of this sample expressed awareness of
social expectations in this area (10). The issue of how much
weight it is appropriate to gain in pregnancy varies according to
time and culture, so the generality of this finding is unclear.

Little is known about problems in quitting during pregnancy.
The role of cigarettes as stimulants or tension reducers may be
altered during this period. Abstinence symptomatology has also
not been documented.

A composite picture of the successful quitter has been drawn
by Baric, et al. and also by Kuzma and Phillips (11,108). Baric, et
al. list educational qualifications as being positively related to
quitting, followed by sickness in early pregnancy. Other distin-
guishing characteristics are smoking fewer cigarettes before
pregnancy (also see 49,171), having started smoking at an older
age, having stopped previously for at least 6 months, having

344
heard about harmful effects of smoking from more sources,
firmly believing that smoking was harmful to the baby, and
finally, being encouraged to stop or being joined in the cessation
effort by their husbands (47,166).

Kuzma and Phillips identified a number of similar character-
istics: higher educational level; greater family income; being
married; being employed; more frequent church attendance;
having a spouse who does not smoke; and no illicit drug use
(106,108).

The characteristics described—advanced educational level,
higher socioeconomic status, wider information base, belief in
stopping for the sake of the fetus, and spousal support—all fit
with a model of behavior change involving information, per-
sonalization, and social norms (63).

Three studies evaluate smoking cessation interventions for
pregnant women (11,41,49). Tables 9 and 10 show reported abs-
tinence figures for two studies. One study (11) showed no dif-
ference between intervention and control groups, and the sec-
ond study (41) showed 50 percent abstinence at 9-month follow-
up for those completing treatment (11,41). This latter result is
very encouraging but is based on a very small sample in an
affluent community where the aforementioned factors of educa-
tional level, high socioeconomic status and orientation toward
professional advice are operative.

RECOMMENDATIONS

The preceding discussion has revealed a number of findings
which may be useful in improving methods of reaching the
pregnant woman and offering her cessation interventions.

1, Pregnant women seem to know that smoking is harmful to
health, and most acknowledge that it can be directly harmful to
the fetus. This information about the baby’s health should be
made as specific as possible, and the mother’s own health should
be intricately interwoven in the theme. Quitting is for the good
of both mother and baby, not the baby alone. The harmful as-
pects of smoking and the benefits of not smoking must be
equally emphasized.

2. Mass media, such as television and film, are particularly
good avenues for portraying women of varying ethnicity in a
number of geographical and socioeconomic settings. Because of
gender identification it is important to utilize women as the
transmitters of information and advice. Information should be
dispensed by as many different sources of contact in the pre-
natal clinic (or doctor’s office) as possible, not solely by the

345
physician. The awazeness of various health professionals
should be raised in this regard.

3. Social norms and lay referral systems should be used as
part of information dissemination and modeling influences.
This is particularly true for women of lower socioeconomic
status. It is important to involve the father of the child in the
normative belief system and in a direct supportive effort of
quitting. This should be particularly timely in an era when more
and more couples are experiencing pregnancy and birth as a
two-person process.

4. Much more emphasis must be placed on permanent smok-
ing cessation rather than just during the time of pregnancy.
Positive aspects of remaining an ex-smoker include better
health for the mother and child and the future impact of role
modeling as the child grows.

Summary

1. The percentage of 17-18 year old women who smoke has
shown a steady rise between 1968 and 1979. It now appears,
however, that the increase in smoking prevalence among all
12-18 year old females has leveled off and begun to decline.
Young women born after 1962 show a substantially reduced in-
itiation of smoking and will probably have a much lower preva-
lence of smoking as adults.

2. Those young women who do begin to smoke are starting to
smoke regularly at a younger age, with more than half of the
male and female adolescents who begin to smoke starting before
the 10th grade.

3. The earlier tobacco is used and the greater the number of
cigarettes smoked per day, the less likely an attempt to quit will
be successful. ,

4. The percentage of women smokers who smoke more than
one pack per day is increasing.

5. Adolescent and.adult women are more likely to use low “tar”
and nicotine cigarettes, smoke fewer cigarettes per day and in-
hale less deeply than do men, but the difference between the
sexes in these patterns of smoking is decreasing. Adolescent
and adult black women are more likely to be smokers than their
white peers, but they smoke fewer cigarettes per day.

6. Adolescents from low income families, single parent
families, and families with lower parental educational levels are
more likely to become smokers.

7. Female and male adolescents are more likely to begin
smoking if a parent or older sibling also smokes.

346
8. Adolescent smokers associate with peers who smoke, and
nonsmokers associate with nonsmoking peers.

9. Adolescent girls overestimate the percentage of their peers
who smoke and they have a very positive image of the people in
cigarette advertisements, but they are less likely than adoles-
cent boys to see smoking as a social asset.

10. Adolescent girls who smoke tend to be more outgoing, but
feel less able to influence their future.

11. Adolescents experience stress due to feelings of unattrac-
tiveness, incompetency in school achievement and personal re-
lations, limited opportunity for personal growth and concern
over future social and economic roles. This stress may be the
common mechanism producing the increased rates of smoking
in some groups.

12. The factors associated with successful quitting by adoles-
cents of either sex are lower number of cigarettes smoked per
day, higher educational aspirations and achievement, greater
acceptance of the health risk of smoking, and having more
nonsmokers among their friends.

13. It is possible that women and men modify their smoking
in order to maintain a constant nicotine level.

14. Women are more likely than men to smoke in order to
reduce stress.

15. Women at higher education and income levels are more
likely to succeed in quitting. Additional factors associated with
successful quitting are a strong commitment to change, the use
of behavioral techniques and reliable social support for quit-
ting. Women have been reported to show lower rates than men
of successful cessation following organized cessation programs,
a difference which is less apparent in those programs that in-
clude social support.

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