Background: Secondhand smoke poses risks to children, particularly those from low socioeconomic backgrounds. Recently, there has been an increase in tobacco-control policies designed to reduce children's exposure to secondhand smoke, including interventions to change parental smoking behaviors. However, little attention has been paid to understanding potential unintended consequences of such initiatives on mothers who smoke. As such, the objectives of this paper are to explore the potential consequences of tobacco-control policies designed to reduce children's exposure to secondhand smoke on socially disadvantaged mothers who smoke and to provide recommendations for research, policy, and practice. Evidence acquisition: A theory-guided, qualitative narrative review of the perceived discrimination, stigma, and stress and coping literature was conducted. MEDLINE and PsycINFO were searched to identify relevant articles from 1980 to October 2008 for review. Evidence synthesis: There is evidence that strategies designed to reduce secondhand smoke have contributed to smoking stigmatization. However, there is little research on the consequences of these initiatives or how they affect low-income mothers who smoke. Stigmatization research suggests that such policies may have unanticipated outcomes for socially disadvantaged mothers who smoke, such as decreased mental health; increased use of cigarettes or alcohol; avoidance or delay in seeking medical care; and poorer treatment by healthcare professionals. Recommendations for researchers, practitioners, and policymakers are presented. Conclusions: Further research is needed to understand how initiatives to reduce children's exposure to secondhand smoke, as well as broader tobacco-control initiatives, can be designed to minimize potential harm to mothers who smoke.
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A key piece of helping mothers quit is improving their encounters with healthcare providers. To this end, it is important to help providers become aware of and overcome their own biases. 98,110 Bias against mothers who smoke may be particularly difficult to overcome because it may be perceived as legitimate and deserved, given the very real risks that SHS poses to children. Moreover, a preventive orientation in healthcare practice and policy that emphasizes individual lifestyle changes may also increase the likelihood that smokers who cannot successfully modify their behavior will be stigmatized. 111–114 For these reasons, it is particularly important that guidelines and initiatives aimed at providers include the aims of: (1) sensitizing providers to the stigma of tobacco use, and (2) mitigating tendencies to “blame” smokers by increasing awareness of the factors that promote smoking and make quitting difficult (e.g., environmental factors, addiction). There is growing evidence that specific alterable factors can reduce the likelihood of conscious and unconscious biases influencing healthcare providers' judgments, decision making, and the way in which they communicate with patients. 110 A key step is to make providers aware of their biases and to enhance internal motivation to reduce this bias. To accomplish this, it will be necessary to raise awareness about the potential stigmatization that mothers who smoke may feel when reminded of the harm they are doing to their children, and to educate providers about the deleterious consequences of stigmatization, including how stigmatization may be counterproductive to building an effective patient–provider relationship and potentially inhibit the goal of reducing SHS exposure. Another component involves building empathy: helping providers “put themselves in the shoes” of the mother who smokes and to understand, from her perspective, the particular barriers she faces in her struggle to protect her child from SHS. It is also important to help providers improve their partnership-building skills, particularly with patients who might evoke strong negative emotional reactions in them. These strategies are likely to be welcomed by pediatricians and other healthcare providers who report low levels of effectiveness and training in smoking cessation counseling. 115 The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. This project was supported by a Merit Review Entry Program (MREP) award to Dr. Burgess from the VA Health Services Research & Development (HSR&D). Dr. Fu is supported by a Research Career Development Award from VA HSR&D. No financial disclosures were reported by the authors of this paper.