‘Smoking during pregnancy can cause serious pregnancy-related health problems. These include complications during labour and an increased risk of miscarriage, premature birth, stillbirth, low birth weight and sudden unexpected death in infancy.’ This was cited recently in a Health and Social Care Information Centre report (HSCIC, 2016: 5), showing that in 2015/16 in England, 10.6% of women giving birth were recorded as smokers at the time of delivery. The prevalence was 15.1% in 2006/07 and 11.4% in 2014/15.
Although Louise Silverton, director of midwifery at the Royal College of Midwives, said it was ‘positive’ to see this reduction in smoking prevalence rates, she highlighted the importance of retaining local authority funding for family-based smoking cessation to include pregnant women. Silverton added: ‘We know that women in poverty are more likely [to] smoke so extra help and support [must] be given.’ According to the Department for Communities and Local Government (2015): ‘Middlesbrough, Knowsley, Kingston upon Hull, Liverpool and Manchester are the local authorities with the highest proportions of neighbourhoods among the most deprived in England.’ So it is, perhaps, unsurprising that the HSCIC (2016) report found that smoking prevalence ranged from 16% in the North West and North East of England to 4.9% in London.
How can the relatively high prevalence of smoking among pregnant women from lower socioeconomic groups be addressed? A Dutch randomised controlled trial of a nurse-led home visitation intervention trial conducted over a 2.5-year period among 460 pregnant women from lower socioeconomic groups, found that during pregnancy 40% of smokers were in the intervention group, significantly lower than 48% of smokers in the control group; after birth, those in the intervention group smoked 50% fewer cigarettes than the control group; and breastfeeding duration was longer in the intervention group (Mejdoubi et al, 2014). From an ethical point of view, targeted interventions like this study raise the question of the role played by stigmatisation in public health matters. For example, the stigmatisation of particular groups that occurred when the first cases of AIDS were identified in the 1980s still exists, and as BBC News (2016) recently reported, in September 2016 Northern Ireland is set to lift the lifetime ban on gay men in donating blood.
Bayer (2008: 468) detects a ‘new morality’, where obese people are stigmatised as ‘letting themselves go’ and smokers as ‘having no willpower’. And where taxing of cigarettes is concerned, ‘those who continue to smoke, who cannot or will not give up cigarettes… [are] compelled to endure a tax that serves the interest of others.’
But it could also be argued that where it concerns the interests of others who have no voice—in this case, the unborn child—stigmatisation of pregnant smokers is an acceptable public health tool. Yet a nagging question remains: is the judicious application of stigma an appropriate form of social control? After all, the stigmatisation of injecting drug users hardly represents an emphatic victory for public health.
So should more room be given to liberalism in the context of public health ethics? Considering this question, Rajczi (2016: 96) defines liberalism as ‘the view that liberty is a prime value and the state needs strong justification for infringing upon it’, and cites one argument claiming that in the context of anti-smoking measures, such a definition of liberalism could rule out ‘increased tobacco taxes, advertising bans and regulations, smoking bans and restrictions, public health campaigns, and publicly funded stop-smoking helplines and other resources.’ In which case, it seems that where public health is concerned, there is a good argument in favour of limiting the wholesale application of liberalism's worthy tenets. A liberal democracy is best preserved by governments enforcing measures that recognise the difference between freedom in a society and a society which is a free-for-all.
Another approach would be to simply ban smoking. In a recently reported Swiss study, Vicedo-Cabrera et al (2016) evaluated how regional smoking bans introduced in 23 of Switzerland's 26 cantons at different points in time affected birth outcomes, including preterm and early-term births. The researchers noted: ‘This is the first study to show a clear dose-response relationship between smoking bans and the risk of preterm births, with greater benefits in cantons that adopted more comprehensive smoking bans.’
With a burgeoning evidence base to show how smoking in pregnancy damages fetal health, there is a clear role for midwives in promoting the anti-smoking message among pregnant women and those contemplating pregnancy. One challenge facing midwives is that of reconciling the tension between public health and individual freedoms. It seems sensible that, where smoking in pregnancy is concerned, an individual's freedom to smoke should be denied by all legal means.