Activities of the healthcare team for women who smoke during pregnancy and the puerperium

OBJECTIVE: to identify activities developed by the healthcare team for pregnant and postpartum women who smoke. METHOD: cross-sectional study with a sample of 135 healthcare team members who assist pregnant and postpartum women in a university hospital located in southern Brazil. The data was collected using questionnaires and analyzed using the Statistical Package for Social Sciences software. RESULTS: 76 (56.3%) staff members reported that they always addressed smoking cessation; however, the approach occurred in only two periods of the hospitalization and/or prenatal consultations, not including family members. In regard to the effectiveness of their actions, the health team assessed it as fair or poor, and mentioned the need for updating knowledge regarding this issue. CONCLUSIONS: the health team did not perform the approach as recommended by the tobacco control guidelines, requiring training to offer a qualified and efficient intervention.


Introduction
In Brazil, on average, 1,600 women die each year due to pregnancy, childbirth and postpartum issues and 50,000 children die under the age of one year. Among the causes are the complications associated with use of substances during pregnancy, including nicotine (1) .
Studies from Southern Brazil revealed a prevalence of smoking among pregnant women from 23% to 27.5%, high rates when compared to the adult female population, which is 15.9%. Pregnant smokers also have lower education levels and conduct fewer prenatal visits than non-smokers. Among the smokers studied, only 1.19% received some type of care/medication treatment for smoking cessation (2)(3) .
Considering these data and given that the period of pregnancy, childbirth and postpartum is a moment when a woman is more likely to interrupt her smoking behavior, because the baby motivates her to look after her own health and she starts to have more contact with healthcare professionals (4) , the performance of cognitive-behavioral approach is recommended for pregnant and postpartum smokers. This approach consists of preparing them to address their problems and resist smoking; preventing relapse and coping with stress; and, in cases of high dependence on nicotine, providing medication therapy support. The cognitivebehavioral approach is considered the basis of the intervention, essential for smoking cessation, with data suggesting a cessation rate directly proportional to the time devoted to this approach (5)(6) .
One systematic review showed that health professionals used standardized instruments to identify the smoking profile, nicotine dependence, craving, abstinence and motivation for cessation, in order to help them to intervene in the health education process in these patients (7) .
On the other hand, a study conducted in Southern Brazil, with medical and surgical patients, showed that actions performed by nurses were aimed toward the rules guiding the prohibiting of smoking in the institution, and about the possibility of smoking cessation without the use of specific instruments or cognitive-behavioral approach (8) , a fact that identifies knowledge gaps on this subject.
Thus, considering the need to improve the actions for smoking cessation and the situation of pregnancy/ postpartum, which may trigger a positive motivation for this, the present study aimed to identify the activities developed by the healthcare team for pregnant and postpartum smokers. To do so, we defined as actions of the healthcare team every activity, intervention and guidance focused on health promotion in relation to smoking cessation for this population

Methods
This was a cross-sectional study, conducted in a university hospital in southern Brazil. The population consisted of multidisciplinary team members of an obstetric outpatient unit and a pre-and postpartum hospital unit, assisting pregnant and postpartum women. The sample was defined by convenience, not proportionally, and was composed of physicians, nurses, nutritionists, psychologists, pharmacists, social workers, nursing assistant staff, residents and students who agreed to participate.
The sample size was calculated based on a study that showed a prevalence of 61.5% of professionals addressing smoking issues (9) during patient care. Considering a confidence interval of 95% and an acceptable error of 10%, we calculated a sample size of 91 participants.
However, we invited all 170 members of the health teams in the selected units that met the inclusion criteria, with 135 of them agreeing to participate and being included in the present study sample.
The inclusion criteria were: being part of the healthcare team of the units assisting pregnant and postpartum women during the period of data collection, and being students in the second semester of the course or above.
Data collection was conducted using a non-

Results
A total of 135 members of the healthcare team participated in the survey. Their characteristics are presented in Table 1.

This analysis was performed only with members that
showed an n≥10, in order to preserve the identity of the participants ( Table 2).
The association between "address the patient about tobacco issues" and the different team members was statistically significant (p=0.025), as well as the association of "number of approaches" and "team members" (p=0.008). The residual analysis showed that the nursing staff made fewer approaches than expected for each category (Table 2).
When participants were asked about their attitude towards a pregnant or postpartum woman who was resistant to smoking cessation, we obtained the   and postpartum women based on the initial assessment of patient dependence, and medication therapy in specific situations (5) .
In another study, the guidelines of the Ministry of Health regarding the approach to smoking patients were partially followed by slightly more than half of the sample (5) . The unsatisfactory approach observed is reflected in the results of the healthcare team selfassessment in relation to cessation, in which more than 90% rated their action as fair or poor. This highlights the need to review the training of teams to better approach patients and their families.
Medical doctors and nurses were the ones who more often provided assistance to the smoking patient, including the family in this care. This finding is consistent with a study that relates these professionals and the patients' relatives as the major sources of patient interventions and guidelines when it comes to smoking (4) . However, it is known that for the behavior change to occur, much more than two interventions are required; so it is imperative that they occur in a systematic way to actually help this group of patients to quit smoking. Thus, the results point to the need of the healthcare team to review and enhance approaches to the patients and their families.
The nurse assistant staff had the lowest number of approaches and they reported having more difficulty in providing guidance activities, which can be explained by the fact that their training is often focused on developing skills to perform specific tasks and procedures (10) . Taking into consideration that this is the largest professional category in hospital care, and those who have the greatest contact with patients in this setting, the development of training strategies is suggested to enable them to change this reality.
One study showed that devaluation or omission of actions by the health professionals regarding smoking behaviors may be interpreted by the patient/family as it having no relationship to their disease process and recovery (11) . Another study (12) showed that a brief intervention by the health team could be decisive for the patient decision to quit smoking. Therefore, it Rev. Latino-Am. Enfermagem 2014 July-Aug.;22(4):621-8.
is necessary that the interventions occur during all favorable opportunities and by all members of the healthcare team.

The questions, guidelines and medical records
were mainly focused on the identification of smoking status, its characteristics, and information provided for tobacco cessation. Such data is essential in the context of the cessation process, since the choice of the most appropriate treatment is developed based on these.
However, for cessation to occur, the mere collection of data is not enough; the monitoring of patients is necessary, as is the performance of interventions during hospitalizations or in the prenatal consultations, using the cognitive behavioral approach and medications, when necessary.
Counseling was conducted briefly, however the results reinforced the need for guidance to be carried out systematically according to the level of understanding of the patients, so it can be successful. Studies (4,13) showed that pregnant and postpartum smokers had lower educational levels, and some did not fully believe in the harm that tobacco causes to the baby. They also presented a lack of social support and were subjected to stress, which reinforced the need for the support of the staff in this process.
The Fagerström and Motivation scales were used only by medical and nursing students, which may be related to the fact that such instruments are not part of most professionals' field of knowledge (14) . Based on this result, we suggest the training of health teams by distributing these instruments, which assist in driving the choice of the best treatment.
The most commonly performed activity for smoking patients who did not want to quit smoking was providing information about the harm that it can cause to the mother and baby, and the benefits of cessation. This approach meets the Ministry of Health guidelines, which recommend a review of the patient's motivation to stop smoking, or not, and conducting motivational interventions (5) . This approach is essential to help pregnant and postpartum smokers to think about the risks of continuing smoking, and the benefits of quitting.
The prevalence of smoking among health team members was low when compared to the general population, which was 15% (5) . The smokers and abstinent ones had statistically higher mean ages than non-smokers, which can be explained by the fact that, over the past three decades, with legislation and the support of cessation programs, there was a decrease in tobacco use throughout the country (15) . An international study identified a prevalence of 33% of smokers among nursing students, and highlighted the need to discourage tobacco consumption and work toward implementation of programs to train health professionals in tobacco control and effective cessation counseling techniques (16) .
The results of this study show that there is also the need for constant training of the teams on theoretical and/or practical aspects involved in smoking cessation, beginning in the undergraduate period.
The barriers identified by health staff for the tobacco cessation process are worrisome, since a review study (13) showed that the best time to approach these patients and to obtain better results is during the prenatal consultation, when it is possible to achieve cessation rates up to 70%. In addition, over 80% of the

Conclusions
The For this, we need to empower them not only for the correct handling of medication therapies, but also for the proper guidance about the harms of smoking, with the development of skills and techniques capable of breaking the barriers related to lack of time and misinformation, to help these women to quit smoking and remain abstinent. Therefore, the intervention of the healthcare team, even minimal, can help change the course of this history and make a difference to the quality of health of the mother/baby.