ABSTRACT The adverse effects of maternal smoking during pregnancy on both the offspring and women are well known. The main objective of this research article is to provide health professional causal modelling approach to make a more comprehensive assessment of major determinants of smoking behaviour during and after pregnancy and consequently the outcomes of pregnant women smoking which are adversely affecting both the offspring and pregnant women. The causal model based on theory andevidence was modified and applied to material smoking cessation intervention to control the adverse effects of smoking on offspring obesity and neurodevelopment. In this approach a generic model links behavioural determinants, causally through behaviour, to physiological and biochemical variables, and health outcomes. It is tailoredto context, target population, behaviours and health outcomes. The model provides a rational guide to appropriatemeasures, intervention points and intervention techniques, andcan be tested quantitatively. The causal modelling approach showed promising results which can be used to help maternal smoking women to understand the risk of smoking and help them to quit smoking. The regression analysis of maternal smoking women BMI (n = 1000) on offspring BMI was statistically significant, p < 0.05, 95% CI (0.28 - 0.38) and so was the analysis of offspring SBP on maternal BMI for male offsprings, p < 0.05, 95% CI (0.06 - 0.43) but not for female offsprings (p > 0.05). This supported the hypothesis that maternal smoking women BMI during pregnancy is an important determinant of offspring obesity and consequently the risk factors of cardiovascular development. The causal modelling approach is unique as it provides an incentive to health professional to use these models to target any important and modifiable determinants of the maternal smoking behaviour and decrease the risk of adverse pregnancy outcomes for the offspring and the mother.
Cite this paper
Ansari, R. , Dixon, J. , Browning, C. and Ansari, S. (2013) Application of causal model to maternal smoking cessation intervention in pregnancy. Open Journal of Preventive Medicine, 3, 347-354. doi: 10.4236/ojpm.2013.34047.
 Olds, D. (1997) Tobacco exposure and impaired development: A review of the evidence. Mental Retardation and Developmental Disabilities Research Reviews, 3, 257-269.
 Royal College of Physicians (1992) Smoking and the young. Royal College of Physicians, London.
 Matthews, T.J. (2001) Smoking during pregnancy in the 1990’s. National Center for Health Statistics, Hyattsville.
 Mamun, A.A., Lawlor, D.A., Alati, R., et al. (2006) Does maternal smoking during pregnancy have a direct effect on future offspring obesity? Evidence from a prospective birth cohort study. American Journal of Epidemiology, 164, 317-325. doi:10.1093/aje/kwj209
 Power, C. and Jefferis, B.J.M.H. (2002) Fetal environment and subsequent obesity: A study of maternal smoking. International Journal of Epidemiology, 31, 413-419.
 Mullen, P., Richardson, M. and Quinn, V. (1997) Postpartum return to smoking: Who is at risk and when. American Journal of Health Promotion, 11, 323-330.
 Gilman, S.E., Breslau, J., Subramanian, S.V., et al. (2008) Social factors, psychopathology, and maternal smoking during pregnancy. American Journal of Public Health, 98, 448-453. doi:10.2105/AJPH.2006.102772
 Kramer, M.S. (2003) The epidemiology of adverse pregnancy outcomes. An overview. Journal of Nutrition, 133, 1592S-1596S.
 Haustein, K.O. (1999) Cigarette smoking, nicotine and pregnancy. International Journal of Clinical Pharmacology and Therapeutics, 37, 417-427.
 Wakschlag, L.S. and Hans, S.L. (2002) Maternal smoking during pregnancy and conduct problems in high-risk youth: A developmental framework. Development and Psychopathology, 14, 351-369.
 Thapar, A., Fowler, T., Rice, F., et al. (2003) Maternal smoking during pregnancy and attention deficit hyperactivity disorder symptoms in offspring. American Journal of Psychiatry, 160, 1985-1989.
 Davey, S.G. (2008) Assessing intrauterine influences on offspring health outcomes: Can epidemiological studies yield robust findings? Basic & Clinical Pharmacology & Toxicology, 102, 245-256.
 Chen, A., Pennell, M.L., Klebanoff, M.A., et al. (2006) Maternal smoking during pregnancy in relation to child overweight: Follow-up to age 8 years. International Journal of Epidemiology, 35, 121-130. doi:10.1093/ije/dyi218
 Linnnet, K.M., Dalsgaard, S., Obel, C., et al. (2003) Maternal lifestyle factors in pregnancy risk of attention deficit hyperactivity disorder and associated behaviour: Review of the current evidence. American Journal of Psychiatry, 160, 1028-1040.
 Knopik, V.S. (2009) Maternal smoking during pregnancy and child outcomes: Real or spurious effect? Developmental Neuropsychology, 34, 1-36.
 Orleans, C.T., Barker, D.C., Kaufman, N.J., et al. (2000) Helping pregnant smokers quit: Meeting the challenge in the next decade. Tobacco Control, 9, 6-11.
 Weinstein, N.D. (1993) Testing four competing theories of health-protective behaviour. Health Psychology, 12, 324-333. doi:10.1037/0278-618.104.22.1684
 Becker, M.H. (1974) The health belief model and personal health behaviour. Health Education Monographs, 2, 324-473.
 Maddux, J.E. and Rogers, R.W. (1983) Protection motivation and self efficiency: A revised theory of fear appeals and attitude change. Journal of Experimental Social Psychology, 19, 469-479.
 Fishbein, M. and Azjen, I. (1975) Belief, attitude, intention, and behaviour. An introduction to theory and research. Addison-Wesley, Reading.
 Lumley, J., Oliver, S. and Waters, E. (2003) Interventions for promoting smoking cessation during pregnancy (Cochrane Review). The Cochrane Library, Oxford Update Software.
 Fiore, M.C., Bailey, W.C., Cohen, S.J., et al. (2000) Treating tobacco use and dependence. Clinical practice guideline. US Department of Health and Human Services, Public Health Service, Rockville.
 Windsor, R.A., Woodby, L.L. and Miller, T.M. (2000) Effectiveness of agency for healthcare policy and research clinical practice guideline and patient education methods for pregnant smokers in medicaid maternity care. American Journal of obstetrics and Gynecology, 182, 6875. doi:10.1016/S0002-9378(00)70492-3
 Ory, M.G., Jordan, P.J. and Bazarre, T. (2002) The behavior change consortium: Setting the stage for a new century of health behavior-change research. Health Education Research, 17, 500-511. doi:10.1093/her/17.5.500
 Medical Research Council (2000) A framework for the development and evaluation of RCTs for complex interventions to improve health. Medical Research Council, London.
 Conrad, K.J., Randolph, F.L. and Kirby, M.W.J. (1999) Creating and using logic models: Four perspectives. Alcoholism Treatment Quarterly, 17, 17-31.
 Bartholomew, L.K., Parcel, G.S. and Kok, G. (2001) Intervention mapping: Designing theoryand evidencebased health promotion programs. Mountain View, Mayfield.
 Hardeman, W., Sutton, S. and Griffin, S. (2005) A causal modeling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20, 676-687.
 Bauman, L.J., Stein, R.E.K. and Ireys, H. (1991) A framework for conceptualizing interventions. Sociological Practice Review, 2, 241-251.
 Campbell, M., Fitzpatrick, R., Haines, A. et al. (2000) Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321, 694-696. doi:10.1136/bmj.321.7262.694
 McLean, N., Griffin, S., Toney, K., et al. (2003) Family involvement in weight control, weight maintenance and weight loss interventions: A systematic review of randomized trials. International Journal of Obesity and Related Metabolic Disorders, 27, 987-1005.
 Azjen, I. (1991) The theory of planned behaviour. Organizational Behaviour and Human Decision Processes, 50, 179-211. doi:10.1016/0749-5978(91)90020-T
 Godin, G. and Kok, G.J. (1996) The theory of planned behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, 11, 87-98. doi:10.4278/0890-1171-11.2.87
 Sutton, S. (1998) Predicting and explaining intentions and behavior: how well are we doing? Journal of Applied Social Psychology, 28, 1317-1338.
 Armitage, C.J. and Conner, M. (2001) Efficacy of the theory of planned behaviour: A meta-analytic review. British Journal of Social Psychology, 40, 471-499.
 Ajzen, I. and Fishbein, M. (1980) Understanding attitudes and predicting social behavior. Prentice Hall, Englewood Cliffs.
 Ruggiero, L., Tsoh, J.Y., Everett, K., et al. (2000) The trans-theoretical model of smoking: Comparison of pregnant and non-pregnant smokers. Addictive Behaviour, 25, 239-251. doi:10.1016/S0306-4603(99)00029-5
 Prochaska, J.O. and DiClemente, C.C. (1982) Trans-theoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19, 276-288. doi:10.1037/h0088437
 Hardeman, W., Johnston, M., Johnston, M., et al. (2002) Application of the theory of planned behaviour in behaviour change interventions: A systematic review. Psychology and Health, 17, 123-158.
 Glasgow, R.E., Vogt, T.M. and Boles, S.M. (1999) Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89, 1322-1327.
 Windsor, R.A., Woodby, L.L. and Miller, T.M. (2000) Effectiveness of agency for healthcare policy and research clinical practice guideline and patient education methods for pregnant smokers in Medicaid maternity care. American Journal of Obstetrics and Gynecology, 182, 68-75. doi:10.1016/S0002-9378(00)70492-3
 Prochaska, J.O., DiClemente, C.C. and Norcross, J.C. (1992) In search of how people change: Applications to addictive behaviours. American Psychological Association, 47, 1102-1114. doi:10.1037/0003-066X.47.9.1102
 Walsh, R.A., Redman, S. and Adamson, L. (1996) The accuracy of self-report of smoking status in pregnant women. Addictive Behaviours, 21, 675-679.
 Hartmann, K.E., Thorp Jr, J.M., Pahel-Short, L., et al. (1996) A randomized controlled trial of smoking cessation intervention in pregnancy in an academic clinic. Obstetrics and Gynecology, 84, 621-626.
 Pakistan Medical Research Council (1998) National health survey of Pakistan. Health profile of the people of Pakistan, 1990-1994. Pakistan Medical Research Council, Islamabad.
 King, T.K., Borrelli, B., Black, C., et al. (1997) Minority women and tobacco: Implications for smoking cessation interventions. Annals of Behavioral Medicine, 19, 301313. doi:10.1007/BF02892295
 Groner, J.A., Ahijevych, K., Grossman, L.K., et al. (2000) The impact of a brief intervention on maternal smoking behaviour. Pediatrics, 105, 267-271.
 Orlandi, M.A. (1987) Promoting health and preventing disease in health care settings: An analysis of barriers. Preventive Medicine, 16, 119-130.
 Stewart, M.J., Brosky, G., Gillis, A., et al. (1996) Disadvantaged women and smoking. Canadian Journal of Public Health, 87, 257-260.
 Eakin, E.G., Glasgow, R.E., Whitlock, E.P. and Smith, P. (1998) Reaching those most in need: Participation in a planned parenthood smoking cessation program. Annals of Behavioral Medicine, 20, 216-220.
 Valbo, A. and Schioldborg, P. (1994) Smoking cessation in pregnancy: The effect of self-help manuals. Journal of Maternal-Fetal Investigation, 4, 167-170.
 Qureshi, A.A., Wajid, G., Shaikh, I.A., et al. (1992) Ethical considerations for human investigation in Mallick MD. Sample design for the National Health Survey of Pakistan. Pakistan Journal of Medical Research, 31, 289-290.
 Coleman, T. (2004) Special groups of smokers. BMJ, 328, 575. doi:10.1136/bmj.328.7439.575
 Paradis, G., Lambert, M., O’Loughlin, J., et al. (2004) Blood pressure and Adiposity in children and adolescents. Circulation, 110, 1832-1838.
 Apseloff, G., Ashton, H., Friedman, H., et al. (1994) The importance of measuring cotinine levels to identify smokers in clinical trials. Clinical Pharmacology and Therapeutics, 56, 460-462. doi:10.1038/clpt.1994.161
 Ernst, M., Moolchan, E.T. and Robinson, M.L.A. (2001) Behavioural and neural consequences of prenatal exposure to nicotine. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 630-641.
 Floyd, R.L., Rimer, B.K., Giovino, G., et al. (1993) A review of smoking in pregnancy: Effects on pregnancy outcomes and cessation efforts. Annual Reviews of Public Health, 14, 379-411.
 Dolan-Mullen, P., Ramirez, G. and Groff, J.Y. (1994) A meta-analysis of randomized trials of prenatal smoking cessation interventions. American Journal of Obstetrics and Gynecology, 171, 1328-1334.