11

Treating Tobacco Use Treating Tobacco Use During PregnancyDuring Pregnancy

Cecelia A. Gaffney, MEdCecelia A. Gaffney, MEdDartmouth Medical SchoolDartmouth Medical School

May 16, 2005May 16, 2005

22

Smoking Among WomenSmoking Among Women

Health Consequences Health Consequences

Lung cancer is now the leading cause of Lung cancer is now the leading cause of cancer death among US women, cancer death among US women, surpassing breast cancer in 1987.surpassing breast cancer in 1987.

About 90% of all lung cancer deaths among About 90% of all lung cancer deaths among women who continue to smoke are women who continue to smoke are attributable to smoking.attributable to smoking.

33

Smoking Among WomenSmoking Among Women

Health ConsequencesHealth Consequences

Each year during Each year during thethe 1990s, US women 1990s, US women lost an estimated 2.1 million years of life lost an estimated 2.1 million years of life due to smoking attributable deaths.due to smoking attributable deaths.

Women who smoke also experience Women who smoke also experience gender-specific health consequences, gender-specific health consequences, including increased risk of various including increased risk of various adverse reproductive health outcomes.adverse reproductive health outcomes.

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Quitting Smoking during Quitting Smoking during PregnancyPregnancy

“ “Only 18-25% of all women quit Only 18-25% of all women quit smoking once they become smoking once they become pregnantpregnant.”.”

“ “Between 13 and 17% of pregnant Between 13 and 17% of pregnant women smoke in the United women smoke in the United StatesStates.”.”

The Health Consequences of Smoking, A Report of the Surgeon The Health Consequences of Smoking, A Report of the Surgeon General, 2004.General, 2004.

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Call to ActionCall to Action

Smoking is the most modifiable risk Smoking is the most modifiable risk factor for poor birth outcomesfactor for poor birth outcomes

Successful treatment of tobacco Successful treatment of tobacco

dependence can achieve:dependence can achieve: 20% reduction in low–birth-weight babies20% reduction in low–birth-weight babies 17% decrease in preterm births17% decrease in preterm births Average increase in birth weight of 28 gAverage increase in birth weight of 28 g

66

Substance Use in Past Month Substance Use in Past Month Among Women Aged 15-44 YearsAmong Women Aged 15-44 Years

National Household Survey on Drug Abuse, 1994-1996

0

5

10

15

20

25

Pre

vale

nce

(%

)

Cigarettes Alcohol Illicit Drugs

20.6%

2.4% 2.7%

77

Tobacco Use in PregnancyTobacco Use in PregnancyMaternal HarmMaternal Harm

Possible causal associationPossible causal association- - placenta previaplacenta previa-spontaneous abortion-spontaneous abortion

Probable causal associationProbable causal association--ectopic pregnancyectopic pregnancy-preterm PROM-preterm PROM

Causal associationCausal association--abruptio placentaabruptio placenta

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Tobacco Use in PregnancyTobacco Use in Pregnancy Infant Harm Infant Harm

Causal associationCausal association-abruptio placenta-abruptio placenta-small for gestational age-small for gestational age-preterm delivery-preterm delivery-Sudden Infant Death Syndrome -Sudden Infant Death Syndrome (SIDS)(SIDS)-stillbirth-stillbirth

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Effects of Maternal SmokingEffects of Maternal SmokingDuring & After PregnancyDuring & After Pregnancy

““Compared with unexposed infants, Compared with unexposed infants, babies exposed to secondhand smoke babies exposed to secondhand smoke after birth are at twice the risk for SIDS, after birth are at twice the risk for SIDS, and infants whose mothers smoked and infants whose mothers smoked before and after birth are at three to four before and after birth are at three to four times greater risktimes greater risk.”.”

The Health Consequences of Smoking, A Report of the The Health Consequences of Smoking, A Report of the Surgeon General, 2004.Surgeon General, 2004.

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Tobacco Exposure during Tobacco Exposure during Infancy and Early ChildhoodInfancy and Early Childhood

Causal associationCausal association-otitis media-otitis media-new and exacerbated -new and exacerbated cases of asthmacases of asthma-bronchitis and pneumonia-bronchitis and pneumonia- wheezing and lower - wheezing and lower

respiratory illnessrespiratory illness

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Cost of ComplicatedCost of Complicated** Births Births

*Complications include hemorrhage from placenta previa, maternal infection, fetal distress, malposition of the fetus CDC. MMWR 1997;46:1048–1050

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Cost-effectiveness of Smoking Cost-effectiveness of Smoking Cessation InterventionCessation Intervention

JAMA 1997;278:1759–1766

1313

More Missed OpportunitiesMore Missed Opportunitiesin Pregnancyin Pregnancy

61%

21%

81%

22%

80%

25%

0%

20%

40%

60%

80%

100%

Adult PatientVisits

Pregnancy(Adults)

Pregnancy(Adolescent)

Percent ofvisits withsmoking statusidentified

Percent ofsmoker visitswith smokingcounseling

National Ambulatory Medical Care Survey, 1995; Thorndike, et al, 1998 JAMA 279:604-8; 1991 JNCI 91:1957-62

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Intervention Makes a Intervention Makes a DifferenceDifference

Smoking cessation Smoking cessation intervention by clinicians intervention by clinicians improves quit ratesimproves quit rates

Brief counseling works Brief counseling works better than simple advice better than simple advice to quit to quit

Intervention works best Intervention works best for moderate (<20 for moderate (<20 cigarettes/day) smokerscigarettes/day) smokers

A woman is more likely to A woman is more likely to quit smoking during quit smoking during pregnancy than at any pregnancy than at any other time in her lifeother time in her life

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The Evidence-based Intervention The Evidence-based Intervention for Smoking during Pregnancyfor Smoking during Pregnancy

Meta-analyses of randomized trials of Meta-analyses of randomized trials of smoking cessation interventions with smoking cessation interventions with pregnant smokers have concluded that:pregnant smokers have concluded that:

A brief cessation counseling session ofA brief cessation counseling session of5-15 minutes, when delivered by a trained 5-15 minutes, when delivered by a trained provider with the provision of pregnancy provider with the provision of pregnancy specific, self help materials, significantly specific, self help materials, significantly increases rates of cessation among increases rates of cessation among pregnant smokers by 30 to 70 percent.pregnant smokers by 30 to 70 percent.

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5 A’s Approach to5 A’s Approach to Smoking Cessation Smoking Cessation

AskAsk

AdviseAdvise

AssessAssess

AssistAssist

ArrangeArrange

Adapted for pregnant Adapted for pregnant women by ACOGwomen by ACOG

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Disclosure of Smoking StatusDisclosure of Smoking Status

Recent studies confirm non-disclosureRecent studies confirm non-disclosure Non-disclosure rates range from 3% to Non-disclosure rates range from 3% to

13%13%

Concerns with biomarkersConcerns with biomarkers

Structured question still best methodStructured question still best method

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Disclosure of Smoking Disclosure of Smoking StatusStatus

Deception rates, as confirmed by Deception rates, as confirmed by

comparing results of biochemical tests comparing results of biochemical tests

with self-reports, may be high among with self-reports, may be high among

pregnant women, reaching 23% in some pregnant women, reaching 23% in some

groups.groups.

Windsor 2000, Mullen 1991Windsor 2000, Mullen 1991

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Improving DisclosureImproving Disclosure

Which of the following statements best describes your cigarette smoking?

I have never smoked or have smoked fewer than 100 cigarettes in my lifetime

I have never smoked or have smoked fewer than 100 cigarettes in my lifetime

I stopped smoking before I found out I was pregnant and am not smoking now

I stopped smoking before I found out I was pregnant and am not smoking now

I stopped smoking after I found out I was pregnant and am not smoking now

I stopped smoking after I found out I was pregnant and am not smoking now

I smoke some now but have cut down since I found out I am pregnant

I smoke some now but have cut down since I found out I am pregnant

I smoke about the same amount now as I did before I found out I was pregnant

I smoke about the same amount now as I did before I found out I was pregnant

AdviseCongratulatepatient

2020

Spontaneous QuittersSpontaneous Quitters

For the Woman Who Quits For the Woman Who Quits Prior to or Upon Learning of Prior to or Upon Learning of Pregnancy Reinforce her decision Pregnancy Reinforce her decision to quitto quit Congratulate her on success in Congratulate her on success in

quittingquitting Encourage her to stay quitEncourage her to stay quit

2121

Smokers Not Ready Smokers Not Ready to Quitto Quit

5 R’s 5 R’s (or motivational interviewing)(or motivational interviewing)

RelevanceRelevance RisksRisks RewardsRewards RoadblocksRoadblocks RepititionRepitition

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Disclosure of Pregnant Disclosure of Pregnant Woman’s Exposure to SHSWoman’s Exposure to SHSSince you found out you were pregnant, about how many Since you found out you were pregnant, about how many hours a day, on average, are you in the same room with hours a day, on average, are you in the same room with someone who smokes?someone who smokes?

Which of the following statements best describes the rules Which of the following statements best describes the rules about smoking inside your home while you were pregnant?about smoking inside your home while you were pregnant?

No one was allowed to smoke anywhere inside your homeNo one was allowed to smoke anywhere inside your home Smoking was allowed in some rooms or at some timesSmoking was allowed in some rooms or at some times Smoking was permitted anywhere inside your homeSmoking was permitted anywhere inside your home

Source: Adapted from The Pregnancy Risk Assessment Monitoring System, Source: Adapted from The Pregnancy Risk Assessment Monitoring System, The Centers for Disease Control and Prevention, 2002.The Centers for Disease Control and Prevention, 2002.

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Disclosure of Child’s Disclosure of Child’s Exposure to SHSExposure to SHS

A validated, 5-part screening instrument A validated, 5-part screening instrument for assessing child’s exposure has been for assessing child’s exposure has been developed and testeddeveloped and tested

Does child’s mother currently smoke?Does child’s mother currently smoke? In the home?In the home? Does child’s father currently smoke?Does child’s father currently smoke? In the home?In the home? Is your child exposed to cigarette smoke on a Is your child exposed to cigarette smoke on a

regular basis (any exposure at least one time regular basis (any exposure at least one time per week) from anyone other than the parents?per week) from anyone other than the parents?

Source: Seifert JA, et al., 2002.Source: Seifert JA, et al., 2002.

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Treating Exposure to SHSTreating Exposure to SHS

Intervention trials have focused on Intervention trials have focused on parents of children with health problemsparents of children with health problems

Mixed results from trialsMixed results from trials Clinical settings in pediatric and group model Clinical settings in pediatric and group model

HMO have shown some successHMO have shown some success More intensive interventions with More intensive interventions with

biofeedback of child’s cotinine level have biofeedback of child’s cotinine level have lead to significant reductions in exposurelead to significant reductions in exposure

Home based programs show mixed resultsHome based programs show mixed results

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Treating Exposure to SHSTreating Exposure to SHSGood evidence to support use of medicinal Good evidence to support use of medicinal nicotine (MN) as a way to reduce exposure of nicotine (MN) as a way to reduce exposure of childrenchildren

MN is least toxic way to get nicotine for both MN is least toxic way to get nicotine for both the smoker and those living or working with the smoker and those living or working with the smokerthe smoker

Complete substitution of MN for smoking is Complete substitution of MN for smoking is the goalthe goal

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Treating Exposure to SHSTreating Exposure to SHS

If no cessation or use of If no cessation or use of MN, messages should beMN, messages should be Don’t smoke in your Don’t smoke in your

homehome Don’t smoke in your carDon’t smoke in your car

Stress impact of Stress impact of secondhand smoke secondhand smoke exposure on immediate exposure on immediate problem with childproblem with child ear infectionsear infections BronchitisBronchitis asthmaasthma

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Web Resources

Smoke-Free Families:

smokefreefamilies.org

National Partnership:

helppregnantsmokersquit.org