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Characteristics of Inner-City Pregnant Smoking Teenagers Susan A. Albrecht, PhD, RN, Donna Caruthers, MSN, RN
Objective: To describe baseline characteristics of inner-city pregnant adolescent smokers and examine these variables as potential predictors of long-term tobacco abstinence. Study Design: Descriptive study design of the characteristics of pregnant adolescent smokers, with conceptual underpinnings from the Problem-Behavior Theory. Setting: Recruitment and data collection were completed in inner-city outpatient clinics and public schools. Participants: The study enrolled 142 pregnant smoking adolescents. Main Outcome Measures: Self-reported smoking behavior (abstinence vs. smoking) assessed at 12 months from study enrollment was the criterion outcome variable. Variables from Problem-Behavior Theory, tobacco use, and demographics variables were selected as predictors of interest. Results: Twelve months following study enrollment, 123 (87%) participants were smoking, with 19 (13%) reporting abstinence. Pregnant adolescents received messages of encouragement from parents and peers to quit smoking but complicated their pregnancies and smoking cessation efforts by concurrently consuming alcohol during the pregnancy. Conclusion: Findings from this study support previous research on adolescent smokers and extend our knowledge to the inner-city pregnant adolescent smoker. These pregnant teenagers present many needs and challenges for the nurses responsible for their care. JOGNN, 31, 462–469; 2002. Keywords: Adolescence—Inner-city—Pregnancy—Problem-Behavior Theory—Smoking Accepted: March 2002 462 JOGNN
Adolescents living at lower socioeconomic levels in rural and inner-city locations remain vulnerable to tobacco dependency and associated health disorders (Lewis, Harrell, Bradley, & Deng, 2001). Inner-city adolescent women are particularly at risk for smoking compared with their male counterparts (Vanderschmidt, Lang, Knight-Williams, & Vanderschmidt, 1993). From 1990 through 1997, tobacco consumption by adolescents increased, while adult consumption declined and leveled off (Centers for Disease Control and Prevention, 1998, 1999a, 1999b). Selfreported tobacco use among teenagers has remained higher than in adults, with one third of all teenagers smoking cigarettes (Centers for Disease Control and Prevention, 1998; McGinnis & Foege, 1993). The use of tobacco has been termed a pediatric problem because initiation of the behavior generally begins during adolescence. This is an understatement in the case of the pregnant adolescent smoker (Woolf, 1997). Adolescents already are at high risk for pregnancy-related complications such as low birth weight and premature delivery, owing to poor prenatal nutrition (Treffers, Olukoya, Ferguson, & Liljestrand, 2001), but the risk for complications doubles when smoking is a known factor in the pregnant teenager’s health profile (Allen, Moss, Giovino, Shopland, & Pierce, 1993). Smoking-related health risks during pregnancy include ectopic pregnancy, placenta previa, and abruptio placenta (American College of Obstetricians and Gynecologists, 1997). Adverse pregnancy outcomes associated with smoking include preterm birth and perinatal mortality, with smokers nearly twice as likely to have a low-birth-weight newborn (Mathews, 2001). There are additional risks to an infant after birth when exposed to tobacco by his or her smoking Volume 31, Number 4
mother. The infant can be at risk for sudden infant death syndrome, illness-related hospitalizations, and neurodevelopmental abnormalities, including learning disabilities (DiFranza & Lew, 1995; Klonoff-Cohen et al., 1995; Nicholl & O’Cathain, 1992). During the 1st year of life, infants exposed to environmental tobacco smoke are predisposed to lung dysfunction manifested by decreased forced expiratory flow (UEP Agency, 1992), increased incidence of acute respiratory infections, recurrent otitis media (Ey et al., 1995), and hospitalizations for severe bronchitis and pneumonia. Eliminating tobacco exposure is the key to preventing serious health risks for the pregnant adolescent and her infant. Available evidence demonstrates that the population of pregnant adolescent smokers is vulnerable to tobacco dependence, health disorders, and related complications of pregnancy. However, there is a gap in the literature describing the characteristics of pregnant adolescent smokers, particularly those in their 1st or 2nd trimesters of pregnancy with an interest in smoking cessation.
Background Literature Although smoking prevalence is decreasing among pregnant women, discouraging evidence reveals increasing trends in smoking among pregnant adolescents (U.S. Department of Health and Human Services, 2001). Among pregnant adults, study findings suggest smoking prevalence may not change across trimesters (Cornelius, Geva, Day, Cornelius, & Taylor, 1994; Kendrick & Merritt, 1996). However, prevalence of smoking by pregnant adolescents is more dynamic, with reported decreases of 51% in the 1st trimester followed by increases to 62% by the 3rd trimester (Cornelius et al., 1994; Kendrick & Merritt, 1996). Further research is needed to understand this 3rd trimester increase among pregnant smoking teenagers and promote abstinence prior to this spike in tobacco use late in pregnancy. Limited research has demonstrated that race (White), lower socioeconomic level, older age, single-parent household, binge drinking of alcohol, more smoking peers than nonsmoking peers, late menarche, and early sexual promiscuity are predictors of cigarette smoking in pregnancy (Cornelius et al., 1994; Kokotailo, Langhough, Cox, Davidson, & Fleming, 1994). Studies of the smoking adolescent population have identified various predictors of smoking status (e.g., abstinence versus relapse), which include daily tobacco consumption, motivation to quit, and perceived stress (Sargent, Mott, & Stevens, 1998; Sussman, Dent, Severson, Burton, & Flay, 1998). Attitudes and self-efficacy have been found to influence an adolescent’s motivation to quit smoking (Engels, Knibbe, de Vries, & Drop, 1998). Finally, parental attitude and modeling of smoking abstinence behavior are July/August 2002
associated with smoking initiation and smoking abstinence in children and adolescents (Distefan, Gilpin, Choi, & Pierce, 1998; Farkas, Distefan, Choi, Gilpin, & Pierce, 1999). Lifetime tobacco abstinence is a desired and necessary goal, but intervention among adult pregnant smokers has been met with limited success in altering tobacco use and exposure (Ershoff et al., 1999; Walsh, Redman, Brinsmead, Byrne, & Melmeth, 1997). Although interventions with smoking adults have resulted in increased abstinence during pregnancy, postpartum smoking relapse occurs for most women (Ershoff et al., 1999; Stotts, DiClemente, Carbonari, & Mullen, 1996; Walsh et al., 1997). Evidence-based tobacco interventions for pregnant adolescent smokers are lacking, owing in part to a paucity of descriptive and intervention research findings (Backinger & Leischow, 2001; U.S. Department of Health and Human Services, 2001).
Theoretical Perspective Problem-Behavior Theory emphasizes the functional role that smoking and other problem behaviors serve in meeting developmental needs, such as peer group acceptance and separation from parents. This theory encompasses developmental theory and a range of nonnormative health-compromising behaviors within a social-psychologic framework. In Problem-Behavior Theory, four systems (social environment, personality, perceived environment, and behavior systems) help to explain the origin and development of problem behaviors such as smoking during adolescence (Jessor, Donovan, & Costa, 1991). The social environment system encompasses social background and context variables, such as educational attainment, religious affiliation, and family membership. Motivation, self-esteem, and religiosity are some of the concepts included in the personality system. The perceived environment system incorporates social-psychologic variables, such as peer modeling of behavior and compatibility of parent and peer attitudes. Within the behavior system, social behavior variables are categorized as either problem behavior structure (e.g., smoking, substance abuse, sexual promiscuity) or conventional behavior structure (e.g., church attendance, health promotion behavior) (Jessor et al., 1991). This framework suggests that actively engaging in one deviant behavior is likely to lead to experimentation or participation with other deviant behaviors (Jessor et al., 1991). Early research on adolescent girls reported an association between active substance abuse and increased sexual promiscuity (Zabin, 1984), supporting the process of additive deviant behaviors by adolescents. For this research, Problem-Behavior Theory enabled us to go beyond typically used nicotine-dependence frame-
works to study the psychosocial environment of the pregnant adolescent who smokes cigarettes.
Methods Study Objective. The primary objective of this research was to describe baseline characteristics of inner-city pregnant smoking adolescents, including the influences on their smoking outlined in Jessor’s Problem-Behavior Theory and their level of nicotine dependence. The second objective was to examine these baseline characteristics as potential predictors of long-term tobacco abstinence 12 months after entry into a smoking cessation study. Study Design. This descriptive study was part of a larger randomized controlled smoking intervention trial in pregnant adolescents. Based on Problem-Behavior Theory, variables were selected to represent social environment, personality, perceived environment, and behavior systems. Tobacco use (cigarettes) before and during pregnancy and nicotine dependence were also measured to describe cigarette-smoking behavior. Setting and Recruitment. Pregnant teenage participants currently smoking cigarettes were recruited from innercity obstetric clinics and middle school, senior high, and alternative schools to participate in the larger randomized controlled smoking cessation intervention study. Inclusion criteria required participants to be (a) 13 to 19 years of age; (b) a patient of a designated outpatient maternity clinic or student at a designated school; (c) between 12 and 28 weeks gestation verified by a positive pregnancy test and pregnancy dating by health care providers at the teenager clinic or health care provider if other than clinic; (d) able to read, write, and understand English; (e) smoking at least one cigarette per day; (f) single (not currently married); (g) childless; and (h) available by telephone. Exclusion criteria were signs of pregnancy complications (i.e., bleeding, preterm labor) or a need for placement on home study (confined to home by physician). For the larger study, participants were assigned randomly to usual care or one of two intervention assignments, in which a tobacco-dependence intervention was provided in a group setting. Participants. A total of 142 adolescents consented to participate in the intervention study, which was approved for conduct with human subjects by the local institutional review board. Recruitment procedures are discussed in more detail elsewhere (Albrecht, Reynolds, Salamie, & Payne, 1999; Albrecht, Taylor, Braxter, & Reynolds, 2001). Procedures. Baseline data collection was conducted following randomization procedures. All participants had contact with study personnel for three follow-up visits (8 weeks after randomization, after giving birth, and 12 months after study entry).
Instruments. The Health Behavior Questionnaire for adolescent students, a multi-item, multiscale tool, was used to measure Problem-Behavior Theory variables (Jessor et al., 1991). Educational attainment, religious affiliation, and the number of family members in addition to the participant living in the household were selected as social environment system variables. Personality system variables included motivation to quit smoking, self-esteem, and religiosity. Motivation to quit smoking was measured with a scale ranging from 1 through 10, with 10 indicating the greatest motivation to quit smoking. Self-esteem was obtained with a summary score from the 10-item New York Self-Esteem Scale (Rosenberg, 1979). Summa-
he pregnant teenager may receive encouragement to quit smoking but lack the internal reasons and role models necessary to change and sustain smoking behavior after giving birth.
ry scores ranged from 0 to 6, and low scores indicated high self-esteem. Religiosity was measured with a summary score ranging from 4 to 16, derived from four Likert-type scaled items from the Health Behavior Questionnaire (Jessor et al., 1991). Perceived environmental system variables included “Friend models of smoking behavior” and a compatibility score of parents’ versus peers’ attitudes. The variable labeled “Friend models of smoking behavior” was defined as the number among five closest friends who were smokers or ex-smokers. The compatibility of peer versus parent attitudes was measured with a summary score from items on the Health Behavior Questionnaire (Jessor et al., 1991). High scores reflected greater perceived similarity between peer and parent attitudes, from the point of view of the adolescent. Behavior systems variables included problem behaviors in addition to smoking, such as use of alcohol and marijuana before and during the adolescent’s pregnancy. Tobacco use was measured with a Substance Use Questionnaire, which included age of smoking initiation and daily tobacco consumption, number of cigarettes smoked before and at study baseline, as well as minimum and maximum cigarettes smoked in 1 day within 2 months of baseline data collection. Nicotine dependence was measured by a summary score derived from six items of the Fagerstrom Test for Nicotine Dependence (FTND) (Pomerleau, Carton, Lutzke, Flessland, & Pomerleau,
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1994). The Likert-type scaled questions measured the teenager’s prediction of her likelihood of smoking in situations associated with smoking. A maximum score for the FTND was 10, with scores ranging from 6 to 10 indicative of nicotine dependence. The dependent variable of interest was self-reported cigarette smoking behavior 12 months following study entry. Participants were identified as current tobacco smokers if they reported smoking at least one cigarette per day. Data Analysis. Data analyses were completed using the Statistical Package for the Social Sciences for Windows (version 10.1, SPSS Institute, Chicago, IL). Descriptive analyses were performed for baseline variables. Univariate binary logistic regression was used to examine the relationship of each baseline characteristic to cigarette smoking behavior at 12 months. Multivariate binary logistic regression was used to test the role of ProblemBehavior Theory variables and nicotine dependence at baseline in predicting cigarette smoking behavior at 12 months. Treatment group assignment was included as a predictor in all analyses.
Results Description of Sample The 142 pregnant teenagers had an average age of 17 years (SD = 1.3), had begun menstruating at an average age of 12 (SD = 1.7), and most were in the 2nd trimester of pregnancy (mean gestational age = 19 weeks, SD = 7.2). Approximately 49% of the participants described their race or ethnicity as White and 39% as African American. Most of these pregnant teenagers were unaware of their household income, but all lived in lower socioeconomic neighborhoods, as evidenced by their home address zip codes. More than 61% (87) of the teenagers reported living in a household without a father present. Only 18% (26) of the total sample lived in households with both a mother and father present. More than 50% of the participants reported that their mothers, boyfriends, and close friends encouraged them to quit smoking (see Table 1). Most teenagers reported that their physicians encouraged them to quit smoking. However, nurses were not perceived to promote smoking cessation as frequently as physicians, family, or friends. When participants were asked if smoking risks were likely to influence an attempt to quit smoking, 88% (n = 131) reported that smoking risks for the unborn infant were likely to influence their decision, whereas approximately 79% (n = 132) were concerned with smoking risks for the newborn following delivery. Only 49% (n = 131) were concerned with the risk of smoking to their own health. July/August 2002
Baseline Support for Quitting Smoking Variable
91 (64) 64 (45) 24 (17) 84 (59) 41(29) 93 (66) 81 (57) 2 (1)
142 142 142 142 142 142 142 142
Physician urged quitting Nurse (RN) urged quitting Teacher urged quitting Mother urged quitting Father urged quitting Boyfriend urged quitting Close friend urged quitting No one urged quitting
Problem-Behavior Variables Social environment variables of the Problem-Behavior Theory are described in Table 2. Most (106) of the 142 participants had completed a grade in senior high school before enrolling in the study, and only 14 had completed their last grade in a middle school. Another 9 participants had passed a high school equivalency examination. Most of the teenagers (114) reported an affiliation with a religious organization and perceived themselves as moderately religious. On average, participants’ households were composed of 3 individuals and 2 of them were typically smokers, in addition to the pregnant adolescent. The participants perceived themselves as highly motivated to quit smoking, as well as possessing high self-esteem. Their peers were likely to model smoking behavior; none of the participants reported having peers who were ex-smokers. The average score for the compatibility of peers’ versus parents’ attitudes was 5, suggesting that the teenager perceived a moderate similarity between peer and parent attitudes. Variables for the remaining problem-behavior systems are described in Table 3. Most teenagers reported drinking alcoholic beverages and using marijuana prior to their pregnancy. Unfortunately, a greater number reported drinking during the pregnancy than before pregnancy. There appeared to be a decrease in the number of teenagers using marijuana during pregnancy, however. Baseline smoking is described in Table 4. On average, participants began smoking at the age of 12 years and started smoking regularly 1 to 2 years later. Most teenagers were moderate cigarette smokers, consuming at least a half a pack of cigarettes per day prior to their pregnancy. During pregnancy, they attempted to decrease to light smoking (fewer than 10 cigarettes per day) but reported smoking on at least 6 of 7 days. Approximately 50% of the participants had previously attempted to quit smoking. When asked to score situations that very likely could lead to smoking a cigarette, the pregnant teenagers
Social Environment System Characteristics
Baseline Smoking Characteristics
Baseline Variable Last completed grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade High school equivalency Religious affiliation (yes) Number in family household Number of family smokers
1 3 10 29 34 26 17
(1) (2) (8) (23) (26) (20) (13)
9 (7) 114 (86) 3 (3.0) 2 (2.3)
132 136 136
Personality and Perceived Environment Systems Characteristics Baseline Variable Motivation to quit smoking Religiosity Self-esteem Number of smoking friends Number of ex-smoker friends Compatibility of peer vs. parent attitudes Consumed any alcohol before the pregnancy Current consumption of any alcohol Use of any marijuana before the pregnancy Current use of any marijuana
M (SD) 9 11 2 4 0
(1.9) (3.4) (1.3) (1.2) (.88)
139 135 127 142 142
95 (71) 24 (18)
typically acknowledged anger, nervousness, drinking alcohol, anxiety/worry, and feeling irritable. On average, the baseline FTND scores for nicotine dependence were fairly low, suggesting that these teenagers were not heavily dependent on nicotine.
Outcomes Twelve months after study baseline data were obtained, 123 (87%) participants were smoking and 19 (13%) reporting abstinence. Results of the intervention efficacy will be reported elsewhere. In a univariate binary logistic regression analysis, when all demographic and Problem-Behavior Theory variables were examined as 466 JOGNN
Smoking Variable Age at first cigarette Age when started smoking Cigarettes/day before pregnancy Current cigarettes/day Minimum smoked/day Maximum smoked/day Days per week of smoking Made a previous quit attempt Most likely to smoke if angry Most likely to smoke if nervous Most likely to smoke if drinking alcohol Most likely to smoke if anxious Most likely to smoke if irritable Fagerstrom nicotine dependence
12 (2.3) 132 13 (2.1) 132 15 7 7 14 6
(9.3) (4.6) (9.2) (9.9) (1.5)
133 142 139 133 139
140 4 (1.9) 127
predictors of smoking at 12 months while controlling for treatment group assignment, only six variables were predictors of abstinence: nicotine dependence (FTND), religiosity, compatibility of attitudes, maximum number of cigarettes smoked within the past 2 months, maternal encouragement for quitting smoking, and alcohol intake prior to the pregnancy. Treatment group assignment did not affect abstinence at 12 months. In a stepwise multivariate binary logistic regression analysis, only the compatibility of parent and peer attitudes and alcohol intake prior to pregnancy were retained as predictors in the final model. In multivariate logistic regression analysis, the full model, controlling for study intervention assignment and including these two predictors as compared to a constant 2 only model, was statistically reliable, χ (4, n = 111) = 11.9, p < .018, and the regression coefficients were significant at an alpha level of p < .05 (see Table 5). Greater similarity in parent and peer attitudes (odds ratio = 1.54) and no use of alcohol prior to the pregnancy (odds ratio = 5.46) were associated with tobacco abstinence 12 months following study entry. However, the model’s predictive success was limited to 7% for smoking abstinence and 99% for current smoking. The overall predictive success of the model was 87%, primarily reflecting the prediction of current smoking. Volume 31, Number 4
Predictors of Abstinence: Multivariate Logistic Regression Final Model 95% Confidence Interval for Odds Ratio Predictor Compatibility of parent vs. peer attitudes Alcohol use before pregnancy Constant
.44 1.7 –5.13
.21 .78 1.34
4.43 4.89 14.65
Note. Treatment group assignment for the larger study was controlled in the analysis.
Discussion This examination of predictors of long-term smoking status suggested that differences between parental and peer attitudes, as well as the use of alcohol prior to the pregnancy, increased the odds of smoking following delivery. Evidence was less persuasive of the influence of these variables on long-term smoking abstinence. Although these teenage smokers reported moderate cigarette consumption prior to pregnancy, more than half attempted to decrease their smoking to a lighter level during their pregnancy, which is similar to the drop in smoking by pregnant smokers in the 1st trimester reported by Cornelius et al. (1994) and Kendrick and Merritt (1996). Furthermore, although there was great interest in quitting smoking, the expectant teenagers recognized the need to quit smoking primarily for their unborn child and lacked an interest in quitting for personal health benefits. This is
ealth care providers should assess pregnant adolescents for coexisting problem behaviors, specifically cigarette smoking, illicit drug use, and alcohol consumption.
similar to findings with adult pregnant smokers (Curry, McBride, Grothaus, Lando, & Pirie, 2001). The impact of external environmental factors, such as attitudes of parents and peers, role modeling, and connectedness, as protective variables for preventing or changing health risk behavior in children has been demonstrated in other studies (Albrecht, Reynolds, Cornelius, Heidinger, & Armfield, in press; Distefan et al., 1998). Future intervention research with pregnant adolescents may consider using this alignment of attitudes to enhance smoking cessation intervention effort and outcomes. These adolescent smokers were primarily living in single-parent households and perceived their social enviJuly/August 2002
ronment, composed of their mother, boyfriend, and close friends, as collectively supportive of their interest to quit smoking, but many of the teenagers’ supportive significant others were also smokers. Further research is needed to examine whether this double standard of smoking cessation by the teenagers’ significant others is related to short-lived cessation attempts by the pregnant adolescent. In addition, these teenagers lacked models of ex-smokers among their peers. Distefan et al. (1998) noted that access to tobacco and peer modeling were associated with smoking experimentation. Future intervention research may need to target methods of providing successful ex-smoking modeling to this population of smoking adolescents to compensate for the lack of such peer models. This sample of smoking teenagers engaged in an average of three to four problem behaviors. The pregnancy visibly demonstrated their participation in sexual promiscuity. The teenagers also acknowledged consumption of alcohol, marijuana, and cigarettes before their pregnancies. From a clinical perspective, it was alarming that most of these teenagers not only continued to smoke but also drank alcohol during their pregnancies. These findings further support Problem-Behavior Theory, in which deviant behaviors in adolescents are additive (Jessor et al., 1991; Zabin, 1984). Health care provider encouragement to quit smoking was primarily identified with physicians. Less than half of the teenagers considered their nurses supportive of a change in smoking behavior. It is unclear whether the messages from clinic and school nurses were not given or were not salient enough to be remembered. Unfortunately, this finding is consistent with evidence that nurses do not adequately ask patients if they smoke, want to quit, or desire assistance (Sarna, Brown, Lillington, Wewers, & Brecht, 2000). Limitations of this study include the small percentage of participants who reported tobacco abstinence 12 months after the study baseline data were obtained, the small sample size, and the use of self-reported smoking status as the outcome variable. These factors may have had an impact on the power of the regression analyses to identify predictors of long-term smoking.
In summary, this study extends previous support of Problem-Behavior Theory in the adolescent smoker to the pregnant adolescent smoker. The pregnant teenager may receive consistent social encouragement to quit smoking but lack the internal reasons (e.g., personal health benefits) and ex-smoking role models necessary to change and sustain smoking behavior beyond the delivery of her child. Although pregnant adolescent smokers may initially decrease consumption of cigarettes, adequate risk reduction for the mother and child requires sustained abstinence from smoking. Finally, pregnant teenager smokers may complicate their pregnancy by using other substances of abuse, such as alcohol and marijuana.
indings from this study support previous research on adolescent smokers and extend our knowledge to the inner-city pregnant adolescent smoker.
Based on Jessor’s Problem-Behavior Theory, adolescents who engage in one risky behavior frequently engage in others (Jessor et al., 1991). In this sample of pregnant adolescent smokers, besides precocious sexual behavior and underage smoking, more than 90% of the pregnant smoking teenagers concurrently drank alcohol during pregnancy. The detrimental effects of alcohol on the fetus, such as fetal alcohol syndrome, as well as the risks associated with other substances of abuse, reinforce the need for nurses to intervene to reduce or eliminate risky behaviors and their ill effects in this vulnerable population of teenagers. By identifying behavioral characteristics of pregnant adolescent smokers, this study has revealed a range of challenges requiring nursing assessment and intervention.
Acknowledgment The study described in this article was supported with funding by Grant # R01 NR 03233, National Institute of Nursing Research, National Institutes of Health. REFERENCES
Implications for Nursing Practice Because of the vulnerability of the pregnant smoking adolescent, school, obstetric, pediatric, primary care, and public health nurses have a call to action to develop comprehensive and collaborative interventions. Direct care of the smoking pregnant teenager requires a broad assessment of smoking and tobacco exposure of the teenager, her family, and peers. This assessment is necessary to define the extent of environmental tobacco exposure for the pregnant teenager and her unborn child. In addition, this assessment will identify smoking models that may negatively impact smoking cessation efforts by the pregnant teenager. Findings from this study suggest that pregnant teenagers were interested in quitting because of concern for their baby, but felt omnipotent with respect to their personal health. Therefore, counseling interventions targeting smoking-related health effects on smokers, the fetus, infants, and children should be provided to the teenager, her family, and any interested peers. Furthermore, nurses can and should assist with interventions that promote smoke-free home and school environments, which could include smoking cessation programs for the pregnant teenager, as well as her family and friends who smoke. Findings from this study suggest that pregnant smoking teenagers may encounter similar messages for encouragement to quit smoking from parents and peers, regardless of their own smoking status. Agreement between parents and peers of pregnant adolescent smokers provides a window of opportunity to maximize social support for smoking cessation. 468 JOGNN
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Susan A. Albrecht is an associate professor of nursing, University of Pittsburgh School of Nursing, Pittsburgh, PA. Donna Caruthers is a doctoral candidate, University of Pittsburgh School of Nursing, Pittsburgh, PA. Address for correspondence: Susan A. Albrecht, PhD, RN, University of Pittsburgh School of Nursing, 3500 Victoria Street, Rm. 415, Pittsburgh, PA 15261. E-mail: [email protected]