Characteristic Nonsmokers Smokers
No. (male/female) 8 (3/5) 8 (3/5)
Gestational age 39.5 [+ or -] 1.31 39 [+ or -] 1.00
(weeks)
Birth weight (g) 3,268.94 [+ or -] 277.93 3,426.44 [+ or -] 474.20
Mother’s age (years) 25.63 [+ or -] 3.78 25.63 [+ or -] 4.41
Gravidity 2.75 [+ or -] 1.58 2.25 [+ or -] 1.04
Apgar scores
1 min 8.38 [+ or -] 0.52 8.38 [+ or -] 0.52
5 min 9.00 [+ or -] 0.0 8.88 [+ or -] 0.35
Family income 17.81 [+ or -] 15.20 17.50 [+ or -] 15.47
(thousands, $)
The Role of Smoking in the Lives of Low-Income Pregnant Adolescents: A Field Study
by Erma Jean Lawson
INTRODUCTION
Over the past decade, cigarette smoking among female adolescents has emerged as a major social issue. Between 1975 and 1985, initiation of smoking declined among young men while it increased among young women (Pierce, Fiore, Novotny, Hatziandreu, & Davis, 1989). Female adolescents are more likely to smoke cigarettes than are their male counterparts–20% vs. 16%, respectively (U.S. Department of Health and Human Services, 1988). Paralleling the use of tobacco by female adolescents, one million teenage pregnancies occur annually (Alan Guttmacher Institute, 1989). Although the actual percentage is not available, studies have reported that between 28% and 42% of pregnant teenagers smoke (Davis, Trollestrup, & Milham, 1990; Prager, Malin, Spiegler, Van Natta, & Placek, 1984).
Smoking during pregnancy is detrimental to the health of the fetus, the newborn, and to the infant (Butler & Goldstein, 1973; Fogelman, 1980; Harlap & Davies, 1974; Land & Stockbauer, 1987). It has been associated with low infant birth weight (U.S. Department of Health and Human Services, 1983); prenatal and neonatal mortality (Malloy, Kleinman, Land, & Shramm, 1988; Naeye & Peters, 1984); intrauterine growth retardation (Hickey, Clelland, & Bowers, 1978; Sachs, 1987); delayed reading ability (Bulter & Goldstein, 1973); and short attention span (Naeye & Peters, 1984). Duffy and Coates (1989) also found that these risks are greater for teenagers who smoke.
Although a plethora of clinical and behavioral research has focused on smoking among adolescents, few studies have explored tobacco use among low-income, pregnant youths. Type of residence, peer networks, and beliefs about the acceptability of smoking are differing factors among socioeconomic groups and may provide incentives to smoke (Novotny, Warner, Kendrick, & Remington, 1988; McGraw, Smith, Schensul, & Carillo, 1991). To enhance the effectiveness of smoking-prevention programs directed at low-income pregnant adolescents, it is important to understand their perceptions of tobacco use. This paper describes the beliefs and attitudes of smoking among low-income pregnant teenagers. First, it reviews the literature on adolescent smoking. Second, it considers the benefits these teenagers obtain from smoking. Third, suggestions are offered to improve smoking-prevention programs.
DETERMINANTS OF ADOLESCENT SMOKING PATTERNS
Sociodemographic Factors
Female adolescents comprise the largest percentage of new smokers (U.S. Department of Health and Human Services, 1992). Annually, 3 million American young women under age 18 consume 947 million packs of cigarettes (U.S. Department of Health and Human Services, 1992). Thirty-six percent of females who use tobacco smoke a pack or more of cigarettes daily (U.S. Department of Health and Human Services, 1992). Further, female adolescents appear less responsive to smoking-preventive messages and are less likely to quit smoking as compared to male adolescents (Gilchrist, Schinke, & Nurius, 1989). Indeed, being female has been identified as a predictor of smoking status (Brunswick & Messeri, 1984; Goddard, 1992).
Socioeconomic status has been implicated in the onset of cigarette use among adolescents (Brunswick & Messeri, 1984). Teenagers from lower socioeconomic backgrounds are more likely to smoke than are their middle-class counterparts (Eckert, 1983; Murray, Swann, Bewley, & Johnson, 1983). Similar class differences emerge with pregnant smokers (Graham, 1976). Middle-class pregnant adolescents are more likely to reduce or to quit smoking during pregnancy than are those in the lower class (Davis et al. 1990). This difference in smoking patterns may reflect divergent beliefs about tobacco use based on socioeconomic status (Graham, 1976). Moreover, cigarette advertising has influenced low-income youths beliefs and attitudes about tobacco use. Such advertising associates cigarette smoking with financial success, sport participation, and social acceptance. Thus, low-income youths may be particularly attracted to the habit (Barton, Chassin, Presson, & Sherman, 1982; Tunstall, Ginsberg, & Hall, 1985).
In addition to socioeconomic status, educational aspirations have been correlated with smoking (Bewley & Bland, 1977; Krohn, Massey, Skinner, & Lauer, 1980; Thorlindsson & Vihjalmsson, 1991). Low high school scholastic achievement has predicted cigarette smoking in the United States, Scotland, Australia, and England (U.S. Department of Health and Human Services, 1979). Further, cigarette smoking has been linked to truancy (Bachman, Johnston, & O’Malley, 1981); school suspensions (National Cancer Institute, 1977); and lack of participation in extracurricular activities (U.S. Department of Health and Human Services, 1979).
Peer and family influences
The onset of smoking has been related to having a close friend who smokes (Gritz, 1982; Krohn et al., 1980; Johnston et al., 1987). Female adolescents with a best friend who smokes are nine times more likely to be smokers (U.S. Department of Health and Human Services, 1979). In fact, smoking is usually a shared activity with important socializing functions for female youths (Barton et al., 1982; McGraw et al., 1991). Although it is difficult to determine if female adolescents model their behavior after friends or select peers with similar behavior, studies have reported that same-sex friends are influential in the smoking behavior of female adolescents (Barton et al., 1982; McGraw et al., 1991; Gottleib, 1982).
Parental influence has been associated with adolescent cigarette use Borland & Rudolph, 1975; Gottlieb, 1982; Johnston et al., 1987; Nolte, Smith, & O’Rourke, 1983). Children learn the benefits of smoking as well as its acceptability from parents (Silvis & Perry, 1987). The impact of parental smoking patterns has been observed in elementary school students. First graders whose parents smoke perceive it as an acceptable habit more often than do children whose parents do not smoke (Evans, Rozelle, Mittlemark, Hansen, Bane, & Havis, 1978). In families in which both parents smoke, 15.1 percent of female adolescents are smokers compared to 6.5 percent when neither parent smokes (National Cancer Institute, 1980). Further, female youths are more likely to smoke when their mother smokes (Elkind, 1985; Gottlieb, 1982; Nolte et al., 1983).
Young women also emulate the smoking behavior of older siblings (Lanese, Banks, & Keller, 1972; National Cancer Institute, 1980). Youths with an older sibling and a parent who smokes are four times more likely to smoke than those who have no smoker in the immediate family (U.S. Department of Health and Human Services, 1988). The lack of a smoker in the home may indicate an environment that is nonsupportive of smoking. However, most research has focused on the smoking status of family members, not on the type of assistance they provide for smoking prevention. As a result, there has been an absence of research on the ways in which families communicate smoking-prevention messages to adolescents (Doherty & Whitehead, 1986).
Psychosocial Factors
The relationship between tobacco use and deviant behavior has been extensively studied (Silvis & Perry, 1987; Welte & Barnes, 1987). Adolescents who participate in early and unprotected sexual activity and who use marijuana and alcohol are more likely to smoke cigarettes (Gans, Blyth, Elster, Gaveras, 1990). Thus, cigarette smoking has been described as an early manifestation of problem behavior (Hamburg, Kraemer, Jahnke, 1975). Although these behavioral characteristics have been observed in childhood, cigarette smoking becomes an expression of these attributes in adolescence (Silvis & Perry, 1987). As a result, female adolescent smokers have been described as rebellious, thrill-seeking, and disobedient (Clayton, 1991; Gilchrist et al., 1989).
Male and female adolescents appear attracted to cigarette smoking for different reasons (Clayton, 1991; Gilchrist et al., 1989). For example, young males use tobacco to cope with insecurity and to demonstrate male assertiveness (Urberg & Robbins, 1981). Young females use cigarettes to symbolize autonomy and rebelliousness (Gilchrist et al., 1989; Jessor & Jessor, 1977). Thus, they view cigarette smoking as a symbol of independence (Gilchrist et al., 1989; Urberg & Robbins, 1981). This gender distinction of the functions of smoking is significant since smoking-prevention programs targeted at female adolescents have emphasized self-esteem and social-skill building. As a result, the social-skill deficit model may be more appropriate for young males than for young females (Clayton, 1991; Gilchrist et al., 1989).
Beliefs about smoking have also predicted the onset of smoking (Borland & Rudolph, 1975; Gilchrist et al., 1989; U.S. Department of Health and Human Services, 1980). These studies have reported that adolescent smokers demonstrate less knowledge about the negative consequences of smoking, discount the addictive property of tobacco, and negate the risks of experimental smoking as compared to their nonsmoking counterparts. Although most female teenagers believe that long-term smoking is a health hazard, their own smoking is believed to be unrelated to the chronic smoking habit of adults (Silvis & Perry, 1987; U.S. Department of Health and Human Services, 1979). Challenging the “sense of invulnerability” of adolescents has been the basis of current school-based smoking prevention programs (Clayton, 1991; Evans, 1981; Evans & Borgatta, 1980; Evans, Rozelle, Mittlemark, Hansen, Bane, & Havis, 1978; Silvis & Perry, 1987).
Personality Factors
A variety of personality characteristics have been offered to explain the smoking patterns of adolescents. Female smokers have been described as more apprehensive, maladjusted, and nervous than are non-smokers (Brunswick & Messeri, 1984). Additionally, external locus of control (those who believe that an event is controlled by fate, luck, chance or powerful others) predicts cigarette smoking among adolescents (Brunswick & Messeri, 1984; Clark, MacPherson, & Holmes, 1982). Internal locus of control (those who believe that an event is contingent upon their behavior and actions) has been related to smoking cessation. Although there are contradictory findings about the relationship between smoking and locus of control, studies have consistently shown that belief in one’s ability to control events differentiates adolescent smokers from nonsmokers (Clark et al., 1982; Phares, 1976).
Self-esteem has been implicated in tobacco use among adolescents (Jessor & Jessor, 1977; Johnston et al., 1987; Lotecka & Lassleban, 1981; Murphy & Price, 1988). Adolescents who smoke have been identified as possessing low self-esteem and low expectations for future achievement (Johnston et al., 1987). In fact, they may regard smoking as a means of coping with stress, anxiety, and depression associated with lack of self-confidence. Indeed, compared to male adolescents, females cope by “worrying” and then smoke in response to the negative affect of “worry” (Brunswick & Messeri, 1984). Consequently, they have been characterized as negative-affect smokers. Although various postulations have been offered as to why female adolescents smoke, little attention has been paid to the expected benefits of smoking (Robbins & Kline, 1991). According to Fishbein (1980), a decision to smoke is reasonable if teenagers believe that the net effects are more positive than those of not smoking. Confronted with a choice, teenagers will select the course of action with the greater expected gain based on the belief that it will produce the desired outcome (Robbins & Kline, 1991). In fact, tobacco use may have positive benefits for adolescents in general and for low-income youths in particular that outweigh its long-term health consequences (Leventhal & Cleary, 1980). This suggests the need to explore the beliefs of teenagers concerning the benefits they gain from smoking (Robbins & Kline, 1991).
Underlying the present research are the following questions: (1) Why do low-income pregnant adolescents continue to smoke? (2) What are their perceived benefits of tobacco use? (3) What beliefs influence their cessation of smoking?
METHODS
Sample
The sample consisted of 20 primigravidae adolescents who received prenatal care at a public health center. They were predominantly white, Protestant, and were between the ages of 16 and 18 (mean, 16 years) with two years of high school education (mean = 10 years). Seventy percent were white, 30% were African-American, 65% were single, 30% were married, and 5% were separated or divorced.
Procedures
A structured interview guide of 40 open-ended questions was administered. The questionnaire was designed to explore the teenagers’ beliefs and perceptions of tobacco use. Example questions were: “Tell me what you think about smoking during pregnancy; what are the benefits you derive from smoking? Would you start smoking again? What do you like most about smoking?” Additionally, at the beginning of the first interview, subjects were asked the amount currently smoked, the length of time they had smoked, and the type of cigarettes.
The data were collected during two years of field research. The interviews were held weekly until six-weeks postpartum; they lasted from one to two hours, and were audio-taped in the respondents’ homes. Participant observations were conducted over a period of one year in prenatal classes, at high school dances, and community locations such as pool halls, playgrounds, and bowling alleys in order to explore use of tobacco in their social environment.
RESULTS
Smoking Prevalence
As noted in Table 1, 65% of the sample reported smoking a pack of cigarettes daily and 55% reported no history of tobacco abstinence. Seventy percent of the sample began smoking between the ages of 10 and 11 (mean = 12 years). Interestingly, 55% of the respondents smoked Marlboro Lights cigarettes.
Smoking and Weight Gain
The studied population believed that cigarette smoking controlled body weight and that cessation consistently produced marked weight gain. As a result, they endorsed smoking to pacify their craving for “junk foods” and to control their appetite. One subject, for example, explained: “When I smoke, I don’t eat cakes and candy bars. Just think how much weight I would have gained if I did not smoke.” Another remarked: “I don’t snack as much when I smoke, so I keep my weight under control.” Further, these young women believed that cigarette smoking helped them avoid dieting postpartum. For example, a subject who smoked one pack daily before pregnancy and started to smoke additional cigarettes in her second trimester commented: “I smoked one pack a day before I got pregnant. I smoke more now since I’m pregnant. If I put on too much weight now, it would be hard to lose after delivery. I smoke more now ’cause I have trouble with diets.” Another teenager expressed concern about dieting: “I know with smoking I will not have to diet postpartum. I smoke two packs a day now. Before I got pregnant I needed to lose 100 pounds; I can’t think of having to lose more weight by dieting.”
One reason these young women were concerned about weight gain was peer harassment about their body size. For example, one noted: “My friends poke fun at me and call me names ’cause I’m too fat with this pregnancy. I smoke to keep my weight down.” Another remarked: “At school, girls pounce on fat girls. They laugh at them and fight them ’cause they’re too fat. I mean they stay on you till you break. With smoking, my weight can be maintained. I will not get into fights.” Another respondent claimed she was not invited to parties because of her weight. Thus, she smoked to maintain her weight and gain peer approval.
A recurrent theme in the respondents’ perception of smoking was the belief that weight gain inhibited future relationships. One girl explained: “I won’t get another boyfriend if I gain too much weight. I smoke so I’ll be slim and boys will ask me out.” A 16-year-old who smoked two packs of cigarettes daily expressed her views: “I don’t want to quit smoking ’cause I don’t want to gain a lot of weight while I’m having this baby. I want to look good, so I’ll get another dude. Boys I hang with hate fat girls.” Several adolescents initiated drastic measures of weight control including diets, laxatives, and eating only one meal a day. When one girl discovered that smoking did not help her control her weight, she said: “I guess I won’t get married or find a good job or do something with my life ’cause I can’t control my weight even with cigarettes.”
TABLE 1: SAMPLE DEMOGRAPHICS
N = 20
Number Percent
Race
White 14 70.0
Black 6 30.0
Age
10-15 6 30.0
16-18 4 70.0
Education
7th-8th 5 25.0
9th-10th 8 40.0
11th-12th 7 35.0
Marital Status
Single 13 65.0
Married 6 30.0
Separated/Divorce 1 5.0
Regilious
Affiliation
Baptist 11 55.0
Penecostal 3 15.0
Christian 3 15.0
None 3 15.0
How Much Smoke
A pack daily 13 65.0
Pack & 1/2 daily 6 30.0
Two packs daily 1 5.0
Times Quit Smoking
Never 11 55.0
Once 2 10.0
Twice 4 20.0
Several Times 3 15.0
Age Began Smoking
10-12 14 70.0
13-14 2 20.0
15-16 4 20.0
Cigarette Brands
Marlboro Lights 11 55.0
Virginia Slims 2 10.0
Benson & Hedges 7 35.0
Smoking and Pregnancy Although these young women had positive views of children, they reported fear of anticipated labor pain and how long it would last. They saw cigarette smoking as a way to control the pain. Without exception, all believed that cigarette smoking would assure having a smaller baby which would result in a shorter labor and less painful delivery. One explained: “I don’t want a big baby ’cause my labor will be too hard. Just think, if I quit smoking how much bigger I’ll be.” Another said: “I’m afraid I might freak out during labor and delivery. I am so afraid of labor. I want a small baby so my labor will not be hard.” A typical response was: “I want a baby that weighs five pounds or less, so I smoke. With a smaller baby I’ll have a shorter and less painful delivery.” Clearly, for these young women, cigarette smoking provided a sense of mastery over an experience they perceived to be overwhelming. They considered the risks of smoking against the consequences of their failure to manage labor and delivery.
Of great importance in terms of perceptions of smoking was their role models during childbirth. While the subjects reported that most of their friends had children, few could recall women who did not smoke during pregnancy. A typical comment was: “My sister who had twins smoked two packs of cigarettes daily during pregnancy. Her twins weighed five pounds each and they are healthy. Another recalled: “Five of my friends smoked a pack every day. Their babies are healthy.” Although these women experienced a sense of responsibility for the fetus, they were influenced by family members and friends who smoked during pregnancy and delivered “healthy” infants.
Cigarettes as Dependable
Another perception involved the conviction that cigarettes enabled them to cope with parents’ divorce, death, and abandonment. One girl, for example, who had lived in eleven foster homes since birth, described her “bond” to cigarettes: “I just gotta have cigarettes by my side ’cause they’re the only stable thing in my life.” Another young woman whose father had been killed in a drug-related accident said: “Just not having them is the hardest thing. I won’t smoke them, but I’ve gotta have them ’cause they’re my best friends.” Still another said: “I don’t think I can ever stop smoking ’cause cigarettes have been there for me through thick and thin.” Another young woman reflecting upon the difficulties she experienced while living as a runaway, emphasized the importance of cigarettes in her life: “I lived on the streets for ’bout nine months. My mother threw me out of the house. I didn’t own nothing but the clothes on my back and a pack of cigarettes, but they were there for me, and I consider them the only friend I can count on.” And one noted: “People leave you, but cigarettes never do. You know from the beginning that they will always be there.”
Although these youths were aware of the health hazards associated with smoking, their commitment to cigarettes was analogous to a child’s clinging to a favorite blanket or doll. One girl revealed that she kept three packs of cigarettes in her closet in case she needed them. Several young women made a distinction between the possession of cigarettes and the act of smoking. One said: “I just gotta have them nearby, even though I might not smoke them.” In fact, she believed that having the cigarettes actually had helped her reduce tobacco use. She recalled: “I smoke only one or two cigarettes daily, but I must have a pack available. Knowing they are there when needed helps me to reduce smoking.”
Their affinity to cigarettes was related to the view that cigarettes symbolized participation in a consumer-oriented culture. For example, one respondent remarked: “Buying cigarettes is the only thing that keeps me from killing myself. We lived in a shelter for the homeless for six months. Life for me has been hard since I was five years old.” One girl recalled that her family had been on and off welfare, and that two years previously her father had been hospitalized for alcohol-related health problems. The following year, her mother’s hands were burned while working in a fast-food restaurant. While both her parents were unemployed, a fire from faulty electrical wiring destroyed their house. She stated with embarrassment, “I live from day to day, not knowing if the lights would be turned off, phone disconnected, or we’d have food to eat.” She explained the importance of buying cigarettes: “I know it just wastes money when I buy cigarettes, but I don’t drink or use drugs; smoking is the only thing I do for myself. I don’t have money to go to the movies or skating rinks like other kids.” Another 16-year old recalled: “All I do is sit ’round this house and smoke, but I don’t feel too bad ’cause at least I’m doing something like the kids at school. I smoke.” For them smoking was a luxury even though it lacked status–like wearing clothes, owning video recorders, and compact disk players. Similar to Graham’s (1976) observation, for these young women having cigarettes made sacrifices in other areas of consumption easier to tolerate because they provided a substitute for the lack of material possessions.
Cigarettes and Identity Definition
Research has shown that adolescence is a stressful period (Erikson, 1968; Rosenberg, 1979). The transition from childhood to adolescence has been characterized as discontinuous and demanding (Abramowitz, Petersen, & Schulenberg, 1984). Erikson (1968) emphasized that identity formation represents the primary task of adolescence. Consequently, teenagers may smoke to cope with the difficulty of completing this task in a complex society (Barton et al., 1982; Brunswick & Messeri, 1984; Doherty & Whitehead, 1986; Elkin, 1985).
For these youths, identity establishment was particularly difficult due to the lack of positive role models. They believed that tobacco use distinguished them from peers who smoked marijuana and abused drugs. As one girl noted: “I have friends who use drugs and smoke pot, but I just smoke cigarettes. It’s better to smoke cigarettes than to be using drugs.” Additionally, the respondents compared smoking to the antisocial behavior of their friends. One remarked: “I’m better than other girls in the projects who are running around with different boys, selling their bodies for drugs, and writing cold checks ’cause I just smoke.” Another recalled: “I have friends who might get AIDS . . . I just smoke cigarettes.”
In addition, these young women contrasted smoking to conduct that involved their peers in the criminal justice system: “I won’t go to jail for smoking. Two of my friends are in juvenile ‘tention for stealing. I’m glad to be just a smoker.” One girl noted: “I don’t see anything wrong with smoking ’cause it’s not against the law. I was in the juvenile detention center for trafficking and possessing cocaine. I never want to go back there again. I quit those things and I’m proud to be a smoker than a pregnant woman using drugs.” This suggests that these young women considered the immediate consequence rather than the long-term effects of smoking cigarettes.
Some of the girls compared their smoking with their parents’ alcohol and drug abuse. As one noted: “I’m proud to be just a smoker ’cause my parents are alcoholics. My dad is drinking himself to death at age 36. My mother drinks beer every day. I only smoke one cigarette three times a day.” Another remarked: “My mom and stepdad are hospitalized for being drunks. I’m the only one in the house not addicted ’cause I just smoke.” Another said: “I have been grown-up since I was age seven when I helped my mom get off cocaine. My dad is a drunk, and my brother is on drugs. Which is worse–smoking, drugs, or drinking?” Research suggests that people compare themselves with others who engage in more hazardous behaviors (Rothbaum, Weisz, & Snyder, 1982). By comparison one can appear more advantaged than others. In this study, all subjects compared smoking cigarettes–favorably–to the drug abuse of their parents, siblings, and peers.
Coping with Smoking Cessation
Research has shown that smoking cessation is affected by external events (Lindenthal, Meyers, & Pepper, 1972; Shiffman, 1982). Negative emotional states associated with external stressors precipitate relapse (Lindenthal et al., 1972). Similarly, these young women reported that environmental stressors prevented smoking cessation. One, teen for example, could not quit smoking when she discovered that her mother had tried to commit suicide and her family had received an eviction notice. Although another did quit smoking, she relapsed when her boyfriend who was in jail was not allowed out on parole. During another girl’s cessation attempt, she was placed under extreme stress when the telephone and the electricity were disconnected.
Although these young women believed that environmental stressors inhibited smoking cessation, three did quit smoking because of the negative effects of tobacco smoke on their children’s health. One explained: “I know my child will already be poor and have a rough life. He’ll need to be strong. So, I’m trying to quit for him.” Another remarked: “I worry that my baby will be sickly. I worry that he won’t be able to fight for himself if I smoke.” One girl, who also quit smoking explained: “I probably won’t be able to give my child all the things he’ll need in life, but I can make sure he will be healthy.” Without exception, these teens believed that their children would live in an environment where physical fitness, which translated into toughness, would be required. Quitting smoking was a way they could protect the health of their children in an environment characterized by violence, gangs, crime, and drugs.
DISCUSSION AND CONCLUSION
This study has considered the role of smoking in the lives of low-income pregnant adolescents. It has noted that the literature often views smoking to be a result of demographic, personality, and psychosocial factors. In a sample of low-income pregnant adolescents, smoking served as an appetite suppressant to cope with weight gain. Similar to other women, the respondents desired to be thin, and accepted the cultural standards of ideal body weight. This view of physical appearance made it difficult for them to feel attractive if they did not meet the norm of slenderness. As promoted in advertising, the ideal woman is tall and weighs 10 to 15 pounds less than what is feasible for only one percent of the population (Garner, Garfinkle, Schwartz, & Thompson, 1980). In this context, it is not surprising that the women studied internalized society’s dominant value of thinness. Of those who quit smoking, approximately two-thirds gain weight, with the remainder showing little weight change (U.S. Department of Health and Human Service, 1988). Although a number of assumptions have been made with regard to the influence of smoking on body weight, there has been little consensus as to how much weight gain occurs following smoking cessation (Klesges, Meyers, Winders, & French, 1988). Further, there have been few studies to determine if pregnant women gain weight following smoking cessation and for what reasons.
The belief that cigarette smoking decreases the pain and length of labor suggests that this benefit of tobacco use served as an incentive for these youths to smoke. Such enticement may be particularly significant for pregnant adolescents who fear losing control during childbirth. Because they viewed their inability to perform adequately during labor and delivery as a personal failure, they smoked to control childbirth pain through the delivery of a smaller infant. In fact, few studies have explored this use of tobacco by low-income pregnant youths (Ashton & Stepney, 1982; Robbins & Kline, 1991).
For the population studied, tobacco use was also related to identity formation. The respondents believed that cigarette smoking distinguished them from peers and family members who abused drugs. On comparing drug abuse and various antisocial behaviors to smoking, they perceived tobacco use as less of a health hazard. Because they considered tobacco use less risky than behaviors which could involve them in the criminal justice system, their assessment of cigarette smoking depended upon its immediate rather than long-term consequences. In the context of a high-risk environment, smoking behavior may, in fact, be adaptive.
The results of this study also suggests that there may be a link between smoking and experiences of abandonment. These young women often “grieved” the anticipated loss of cigarettes. Although the concept of grief has been expanded to include many types of losses, there are still significant losses which are minimized (Kaczmarek & Backlund, 1991). Research often has neglected to explore the loss of an adolescent’s attachment to cigarettes. Thus, the type of attachment adolescents experience may have an impact on their ability to cope with smoking cessation. Consequently, cessation for some low-income adolescents may involve a profound loss. Moreover, their lack of access to “status goods” resulted in feelings of deprivation. To them, possession of a valued purchase such as cigarettes raised their social status. Indeed, tobacco use has been used as an important symbol of social roles and statuses (Doherty & Whitehead, 1986).
The adolescents inability to stop smoking was related to how they perceived the benefits of smoking. Few studies have explored the benefits and social meaning of cigarette smoking among low-income pregnant adolescents. Instead, investigators have focused on the consequences of smoking for the young mother and for her child. Further, there is little understanding of the functions of smoking and the use of cigarettes in a variety of socioeconomic contexts.
IMPLICATIONS FOR SMOKING-PREVENTION PROGRAMS
The findings of this study have implications for smoking-preventive programs directed toward low-income pregnant youths. Insofar as smoking may be functional for some of these adolescents, it is important that such programs develop techniques that are based on the norms and beliefs of low-income youths. For example, a booklet commonly used in smoking-cessation programs for low-income pregnant smokers presents an older, middle-class women saying that smoking increases the risk of delivering low-birthweight infants. Its effect is more likely to encourage smoking for some teenagers who believe that smaller babies reduce the pain of labor and delivery. It would be more effective for low-income youths to see a person they admire presenting information on the financial burdens of caring for low-birthweight infants. Additionally, smoking-prevention programs that discuss a range of issues such as weight management and childbirth skills would appear to be more successful for at-risk pregnant youths than traditional programs.
To prevent young women from smoking for identity formation, a smoking-prevention campaign that features nonsmoking peers engaged in “tough” and independent actions could help decrease the number of smokers during pregnancy. Previous research has indicated that peer-led prevention programs in which peers provide information about the effects of smoking as well as role-playing methods and videos have been effective in preventing potential smokers from starting (Evans, 1981; Evans & Borgatta, 1980).
Prevention programs that reduce the psychological dependence on cigarettes would appear to be a reasonable approach for low-income pregnant youths. Most programs have used a model that was developed for men and influenced by the needs of the physically addicted (Best & Steffy, 1971). However, studies have identified a broad spectrum of smokers, including those with greater psychological than physical addiction to cigarettes (Lindenthal et al., 1972; Tomkins, 1966). Despite these distinctions, smoking-prevention concepts have been slow to change. Relatively ignored in most programs have been pregnant adolescents whose smoking primarily involves sporadic or psychological dependence. Consequently, it is crucial to incorporate post-smoking cessation support for adolescents who have few environmental incentives for abstinence. Additionally, to counteract the psychological attachment to cigarettes, programs directed toward at-risk groups could consider adopting flexible goals. These would emphasize avoidance of smoking during pregnancy and view success in terms of reduction instead of total abstinence.
Because lack of money is a problem for low-income adolescents, monetary reinforcement might be a useful part of a prevention program. One successful program used the Pregnancy Outcome Lottery (Nowicki, Gintzig, & Hebel, 1984); the names of women who had not smoked for at least two weeks were entered into the lottery for one month. The woman whose name was drawn received a prize worth approximately .00. To provide an incentive not to return to smoking, the winner’s name was placed into the lottery for the following month. Researchers reported that not one of the lottery winners resumed smoking while in the study. Other programs have used money in some manner to encourage nonsmoking and have proven effective (Elliott & Tighe, 1968; Stachnick & Stoffelmayr, 1981). Further, it was found that the young women interviewed valued children. Therefore, programs should emphasize the immediate effects of cigarette smoking on the fetus, infant, and child. This focus may be cost-effective in reducing smoking by teenagers enrolled in public parental programs.
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