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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.101295
RESEARCH AND PRACTICE |
At the time of this study, Lorraine R. Reitzel, Jennifer I. Vidrine, and David W. Wetter were with the Department of Health Disparities Research, M. D. Anderson Cancer Center, University of Texas, Houston. Yisheng Li was with the Department of Biostatistics and Applied Mathematics, M. D. Anderson Cancer Center, University of Texas, Houston. Patricia D. Mullen was with the Center for Health Promotion and Prevention Research, School of Public Health, University of Texas, Houston. Mary M. Velasquez was with the Center for Social Work Research, University of Texas, Austin. Paul M. Cinciripini and Ludmila Cofta-Woerpel were with the Department of Behavioral Science, M. D. Anderson Cancer Center, University of Texas. Anthony Greisinger was with the Kelsey Research Foundation Houston.
Correspondence: Requests for reprints should be sent to Lorraine R. Reitzel, PhD, University of Texas, M.D. Anderson Cancer Center, Department of Health Disparities Research, Unit 125, 1515 Holcombe Blvd, Houston, TX 77030-4009 (e-mail: lrreitze{at}mdanderson.org).
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ABSTRACT |
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Objectives. Associations between subjective social status, a subjective measure of socioeconomic status, and predictors of risk for postpartum smoking were examined among 123 pregnant women (aged 18–24 years) who stopped smoking because of pregnancy. The goal was to identify how subjective social status might influence the risk for postpartum smoking and to elucidate targets for intervention.
Methods. We used multiple regression equations to examine the predictive relations between subjective social status and tobacco dependence, self-rated likelihood of postpartum smoking, confidence, temptations, positive and negative affect, depression, stress, and social support. Adjusted analyses were also conducted with control for race/ethnicity, education, income, and whether participant had a partner or not (partner status).
Results. In unadjusted and adjusted analyses, subjective social status predicted tobacco dependence, likelihood of postpartum smoking, confidence, temptations, positive affect, negative affect, and social support. Adjusted analyses predicting depression and stress approached significance.
Conclusions. Among young pregnant women who quit smoking because of pregnancy, low subjective social status was associated with a constellation of characteristics indicative of increased vulnerability to postpartum smoking. Subjective social status provided unique information on risk for postpartum smoking over and above the effects of race/ethnicity, objective socioeconomic status, and partner status.
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INTRODUCTION |
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Tobacco smoking is the single largest behavioral contributor to disease1 and is an important determinant of socioeconomic disparities in the incidence and mortality of disease.2,3 Pregnancy represents a unique public health opportunity to capitalize on high rates of spontaneous cessation of smoking.4,5 Unfortunately, although up to half of all pregnant women who smoke stop smoking or refrain from smoking during their pregnancies,6–9 the vast majority of women return to smoking after they give birth. Nearly half relapse within 3 months of delivering their babies, and approximately 80% of women relapse within 1 year.6,7,10–12 Thus, there is a critical need to identify simple, easily measured markers of increased risk for postpartum smoking.
Tobacco smoking has become increasingly concentrated among those with the lowest levels of education, income, and occupational status,13–17 and young adult women comprise a growing proportion of these individuals.18,19 In addition to having a higher prevalence of smoking, individuals with lower socioeconomic status (SES; typically assessed by education, income, or occupation20) tend to be less successful at quitting smoking.21–23 This socioeconomic gradient in smoking prevalence and cessation has been demonstrated among pregnant women as well.24 Recent data indicate that smokers with a higher SES are more likely than those with a lower SES to use effective resources for quitting smoking and to have more restrictive home environments in terms of smoking, which appears to partially explain their higher cessation rates.25
Although numerous studies have found that objective indicators of SES, particularly education, were strongly associated with smoking prevalence and cessation, no studies have examined the association between subjective perceptions of SES and predictors of smoking relapse during pregnancy or in the postpartum period (conceivably any time after the birth of a baby, but in most research referred to as the year following birth). Subjective social status reflects an individual’s perception of her or his position in the social hierarchy.26 Subjective social status has been identified as a significant predictor of self-rated health among racially and ethnically diverse pregnant women, even among racial/ethnic subgroups of women for whom objective SES measures were found to be unrelated to self-rated health.20 Unlike traditional objective indicators of SES, such as education and income, subjective social status captures relative class standing in one’s community and taps into perceptions of perceived inequality, and for this reason may demonstrate a stronger relationship with health behaviors.27 Our goal was to examine the relations between subjective social status and established predictors of postpartum smoking within a racially and ethnically diverse, low-SES sample of young adult pregnant women aged 18–24 years.
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METHODS |
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Procedures
We proactively recruited participants in the Houston metropolitan area from a local health care system, and through newspaper, radio, bus, and clinic advertisements, based on their interest in participating in a clinical trial evaluating a postpartum smoking relapse prevention treatment. Participants for this study were a subset of women aged 18–24 years who enrolled in the clinical trial. Data were collected at the time of study enrollment, and women were compensated with $40 in Walmart giftcards for their time. Women received no intervention prior to data collection.
Participants
Participants were 123 pregnant women who stopped smoking either during their pregnancy or within 1 month before becoming pregnant. Participants smoked an average of at least 1 cigarette daily prior to pregnancy and were in their 30th to 33rd week of pregnancy at the time of study enrollment. Abstinence from smoking was biochemically verified at enrollment through expired carbon monoxide levels.
Demographics and Subjective Social Status
All measures in this study were completed using a computer. Demographic variables included race/ethnicity, educational level, household income, and partner status (had a current spouse or partner versus no current spouse or partner). We categorized race/ ethnicity as a 4-group categorical variable: non-Hispanic White, non-Hispanic Black, Hispanic, and Other. Educational level was dichotomized as less than a high school education versus a high school education (or general equivalency diploma) or greater. Income was also dichotomized, with total household income less than $20 000 per year versus greater than or equal to $20 000 per year. Educational level and income reflect objective measures of SES. Partner status was dichotomous: current spouse or partner versus no current spouse or partner. Marital status was also examined, but partner status was used in all analyses because it exhibited stronger relationships with the postpartum smoking risk variables than did marital status.
Subjective social status was measured using the MacArthur Scale of Subjective Social Status, developed by the John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health.26 The SES ladder version of the scale was used, which pictorially presented a ladder with 10 numbered rungs. Participants were asked to imagine that the ladder represents where people stand in society, with higher rungs representing higher status (i.e., more money, more education, and better jobs).27 Participants were asked to select the rung that best represents where they think they stand relative to others in society. This scale has demonstrated test–retest reliability as well as construct and criterion-related validity among various racial/ethnic groups and in various geographic locations.20,27–29
Postpartum Smoking Risk Variables
Smoking dependence.
Dependence was assessed with 3 single items (time to first cigarette of the day, years smoked, and average cigarettes per day) and with a multidimensional scale. The Wisconsin Inventory of Smoking Dependence Motives (WISDM–68) is a multidimensional measure of dependence that yields an overall smoking dependence score as well as subscale scores for other critical dimensions of dependence (e.g., emotional attachment to cigarettes [affiliative attachment], habit strength [automaticity], craving, smoking for weight control). The overall and subscale scores have high internal consistencies, and high scores are predictive of smoking relapse.30
Likelihood of smoking. Likelihood of postpartum smoking was assessed with the following item: "How likely are you to smoke in the first 6 months after the baby is born?" Response choices ranged from 1 (not at all likely) to 5 (extremely likely). Previous research has shown that endorsement of likelihood of smoking is predictive of positive smoking status over time.31
Confidence. The Self-Efficacy/Confidence Inventory is a 9-item scale reflecting confidence in coping with high-risk situations without relapsing, with higher scores indicative of increased self-efficacy and confidence.32 Self-efficacy and confidence predicted the maintenance of abstinence during a quit attempt among postpartum women in previous studies,33 and low levels of self-efficacy and confidence have been associated with relapse to smoking in general populations.34
Temptations. The Temptation Inventory is a 9-item scale reflecting the intensity of urges to smoke across different situations, with higher scores associated with greater temptations.32
Depressive symptoms. The Center of Epidemiological Studies Depression Scale (CES-D) was developed to assess depressive symptoms in community nonclinical populations.35 Good psychometric properties of the measure have been demonstrated across different populations36,37 and the CES-D has been predictive of smoking relapse.38 Higher scores are associated with greater depressive severity.
Stress. The Perceived Stress Scale (PSS) is a 4-item measure designed to assess the degree to which respondents have experienced stress in the past month.39 Internal consistency is good, and higher PSS scores are predictive of smoking relapse.40–42
Positive and negative affect. The Positive and Negative Affect Scale (PANAS) is comprised of 2 mood subscales: positive affect and negative affect.43 Alpha reliability ranges from .86 to .90 for positive affect and .84 to .87 for negative affect. Negative affect subscale scores have been among the best predictors of relapse in previous studies.42 Elevated scores of these measures are indicative of greater positive affect or negative affect, respectively.
Social support. Social support was assessed with the Interpersonal Support Evaluation List (ISEL–12), a 12-item measure that assesses the perceived availability of social support across a variety of situations.44 Higher scores indicate greater levels of social support, and greater social support has been associated with the maintenance of abstinence during a quit attempt.45 In addition to the total score, the ISEL–12 also has 3 subscales that represent discrete functions of social support: appraisal (availability of someone to talk with about problems), belonging (availability of people with whom one can do activities), and tangible support (instrumental aid).44
Data Analysis
We examined the associations between subjective social status and established predictors of risk for postpartum smoking (dependence, likelihood of smoking, confidence, temptations, depression, stress, positive affect, negative affect, and social support). Both unadjusted and adjusted multiple regression analyses were performed to examine these relations. The unadjusted analyses examined the independent association of subjective social status with each risk variable, whereas the adjusted analyses examined the influence of subjective social status on each risk variable after race/ethnicity, education, income, and partner status were controlled. These covariates were selected to isolate the effect of subjective social status over and above the effects of other commonly reported demographic variables.
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RESULTS |
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The average age of the participants in the sample was 22.00 years (SD = 1.24), and 74% reported having a partner (but only 16.3% were married). The racial/ethnic distribution of the sample was 38.2% non-Hispanic White, 30.9% non-Hispanic Black, 27.6% Hispanic, and 3.3% Other. Of the 123 participants, 21.2% reported less than a high school education. The sample was generally of low SES, with 39.8% reporting a total household income of less than $20 000 per year and only 18 participants declining to report. Prior to pregnancy, participants smoked an average of 10.84 (SD = 7.34) cigarettes per day for an average of 4.54 years (SD = 2.52), with 29% smoking their first cigarette within 5 minutes of waking.
Subjective social status did not differ significantly by race/ethnicity, education, income, or partner status groups (Table 1
). Subjective social status demonstrated more consistent associations with the predictor variables than did other demographic variables (Table 2). In the unadjusted analyses, subjective social status was significantly associated with likelihood of smoking, confidence, temptations, the WISDM-68 total score, and 12 of the 13 WISDM-68 subscale scores (Table 3). Lower subjective social status was associated with greater likelihood of smoking, less confidence, and more severe temptations. For the WISDM-68 total score and all significant sub-scale scores, lower subjective social status was associated with higher dependence. After adjustment for race/ethnicity, education, income, and partner status, subjective social status remained a significant predictor of likelihood of smoking, confidence, temptations, the WISDM-68 total score and 10 of the 13 WISDM-68 subscales (Table 3). Again, lower subjective social status was associated with greater reported likelihood of postpartum smoking, less confidence, more severe temptations, and greater dependence.
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In the unadjusted analyses, subjective social status was associated with positive affect; negative affect; and total, appraisal, belonging, and tangible scores from the ISEL-12 (Table 4
). Subjective social status remained significantly associated with each of these variables in the adjusted analyses. In addition, the association of subjective social status with depression and stress approached statistical significance in the adjusted analyses (Table 4). Lower subjective social status was associated with more depression, greater stress, less positive affect, greater negative affect, and lower levels of perceived social support.
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Moderator analyses were performed to test for significant interactions between subjective social status and the covariates (i.e., race/ethnicity, education, income, and partner status) with respect to their associations with the predictors of risk for postpartum relapse. Only 6% of the interaction terms were significant, which suggests that they occurred by chance. Therefore, those results are not presented.
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DISCUSSION |
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Because up to half of all female smokers quit during pregnancy, pregnancy represents a unique opportunity to improve public health. Specifically, cessation during pregnancy and the maintenance of this change in the postpartum period positively impacts the mother’s health and reduces the increasingly well-documented detrimental effects of maternal smoking on children’s health.46,47 However, this public health opportunity is not being fully realized, in large part because of high rates of return to smoking in the postpartum period. The investigation of key characteristics associated with predictors of risk for postpartum smoking can help identify targets for intervention as well as individuals who are most at-risk for relapse to postpartum smoking and in need of special intervention. Because previous studies have found that younger mothers have a higher risk of postpartum smoking relapse than older mothers,48 the focus on young pregnant smokers is of particular importance in the pursuit of this important public health goal.
The current study provides the first evidence that young pregnant women with low subjective social status display a constellation of characteristics reflective of increased vulnerability to postpartum smoking. Our results indicate that subjective perceptions of low social status were positively associated with tobacco dependence, self-rated likelihood of smoking after childbirth, temptations, and negative affect and negatively associated with confidence, positive affect, and social support. All of these variables have been cited as factors influencing a return to smoking in the postpartum period.5 Moreover, results indicate that subjective social status remained significantly associated with these predictors of risk for postpartum smoking after control for race/ethnicity, objective SES indicators, and partner status. An association of subjective social status with depression and stress also approached significance in the adjusted analyses. Together, these results suggest that subjective social status may be a key marker of vulnerability to postpartum smoking relapse among young pregnant women who quit smoking during their pregnancies and that subjective social status is incrementally predictive of vulnerability to postpartum smoking over and above the more traditional indicators of SES and other demographics.
The finding that subjective social status yields unique information on health-related factors over and above the influence of objective SES is not new. Previous studies with adults have reported similar findings, with subjective social status demonstrating stronger associations with self-rated physical and mental health than traditional objective SES indicators.26,27 Nevertheless, this is the first smoking-related study to explore and demonstrate this phenomenon among pregnant women.
One interpretation of these results is that subjective social status represents a comprehensive measure of relative standing in one’s community that incorporates a range of objective SES factors including job, housing, and financial status. Subjective social status assesses how individuals feel about themselves relative to others and may capture a more global sense of social status than do individual SES indicators alone.26 In addition, subjective social status encompasses feelings of perceived inequality between self and others. This comparative dimension may account for the associations between subjective social status and some of the affective variables found in this study. Previous studies have demonstrated that perceptions of inequality evoke a range of negative emotions among those with lower subjective social status including depression, alienation, anxiety, anger, and poor self-esteem.49
Importantly, subjective social status was consistently associated with indicators of risk and there were very few cases in which objective indicators of SES were better predictors of risk (Table 2
). In adjusted regression analyses, education was an exception to this pattern in that it significantly associated with the WISDM-68 subscales of automaticity (i.e., habit strength; P= .024) and social–environmental goads (belief that social stimuli and context provokes smoking; P= .020), as well as depression (CES-D; P= .014), whereas social status did not.
Also interesting is the failure of traditional dependence measures (time to first cigarette of the day, years smoked, and average cigarettes per day) to demonstrate association with subjective social status or any of the objective SES measures. For young pregnant women who quit smoking, relatively gross measures of the physiological aspects of tobacco dependence (e.g., cigarettes per day) appear to be less sensitive with respect to detecting the effects of subjective social status than are sophisticated, theoretically based, multidimensional models (i.e., WISDM-68 and its subscales).
Unfortunately, our results indicate that women with a lower subjective social status are likely to face significant hurdles in remaining abstinent from smoking in the postpartum period, which suggests the need for increased attention to targeting and intervening with this high-risk subgroup of pregnant women. The results also point to potential points of intervention that can be incorporated into relapse prevention programming. For example, interventions that target multiple dimensions of tobacco dependence (e.g., affiliative attachment) rather than simply physiologically based approaches (e.g., minimizing withdrawal) appear to warrant investigation.
Limitations of the current study include the cross-sectional design and the absence of pre- and postpartum relapse data. This limitation impacts our ability to assess the effect of subjective social status on relapse or the mechanisms of relapse over time. Future studies in this area will benefit from longitudinal designs. Other limitations include the small sample size for women of "other" races (n = 4). Also, the potential for selection biases exist because women who participated in the clinical trial are likely to have been different from women who chose not to participate in the study (e.g., they may have had higher levels of motivation to quit). Finally, we did not analyze other factors associated with risk of relapse, such as smoking pattern with previous births, which might have influenced social status and its relationship with predictors of risk.
In 1998, Najman et al. indicated that the prevention of postpartum relapse to smoking should be viewed as a "major public health priority."24(p60) Unfortunately, little progress toward halting the high rates of postpartum smoking relapse has been made to date,50 and enhancing rates of smoking cessation and the maintenance of that cessation among women during pregnancy and after giving birth remains an important public health goal.51 Our study provides the first evidence that perceptions of social status among pregnant women who quit smoking during pregnancy are associated with a range of critical risk factors for return to postpartum smoking.
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Acknowledgments |
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This study was supported by the National Cancer Institute (grant R01CA89350) and the Centers for Disease Control and Prevention (grant K01DP000086).
Human Participant Protection
The University of Texas M. D. Anderson Cancer Center institutional review board approved this study.
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Footnotes |
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Peer Reviewed
Contributors
L. R. Reitzel, J. I. Vidrine, and D. W. Wetter conceptualized the research question, conducted the data analysis, interpreted results, and wrote the article. Y. Li reviewed the data analysis and results sections of the article and contributed to the analysis. P. D. Mullen, M. M. Velasquez, P. M. Cinciripini, L. Cofta-Woerpel, and A. Greisinger helped with the conceptualization of the overall project and methodology and reviewed and edited drafts of the article.
Accepted for publication February 7, 2007.
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