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Tobacco Cessation Interventions in Pregnancy
Eric L. Johnson M.D.
Physician Consultant
North Dakota Tobacco Quitline/Quitnet
Assistant Professor
Department of Family and Community Medicine
University of North Dakota
School of Medicine and Health Sciences
Objectives
• Assess status of Tobacco Cessation Interventions for Pregnant Patients by OB/GYN providers in North Dakota
• Translate this data into effective practice for OB/GYN providers
• Understand current Tobacco Cessation Interventions for Pregnant Patients
Tobacco Cessation Interventions by OB/GYN Providers in North
Dakota• Study by UNDSMHS NORTHSTAR
Research
• 7 question survey
• Mailed/e-mailed to 110 OB/GYN providers in North Dakota (OB/GYN, FP Physicians and Mid-levels) *
• 73 surveys returned (65% of total)*list compiled with assistance from North Dakota Chapter of the American College of Obstetrics and Gynecology
Results
Do you provide care to pregnant patients in your
practice?93.2%
6.8%
0%10%20%30%40%50%60%70%80%90%
100%
Yes No
Do you assess pregnant patients for tobacco use?
98.6%
1.4%0%
10%20%30%40%50%60%70%80%90%
100%
Yes No
Do you offer tobacco cessation options to pregnant patients?
94.5%
5.5%
0%10%20%30%40%50%60%70%80%90%
100%
Yes No
Which of the following cessation tools are offered in
your practice?89.0%
4.1%
28.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Information Pamphlets, TipSheets, etc
Videos Self Help Manuals
Are any of these materials designed exclusively for
pregnant women?
24.7%
75.3%
0%10%20%30%40%50%60%70%80%90%
100%
Yes No
Do you offer counseling to pregnant patients regarding
tobacco cessation?89.0%
11.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Yes No
What types of counseling do you offer pregnant patients for tobacco
cessation?
78.1%
20.5%
60.3%
69.9%
0%10%20%30%40%50%60%70%80%90%
100%
In Office BriefCounseling
In HospitalCounseling
Referral to tobaccocessation
program/class
Referral to the NDTobacco Quitline
Do you prescribe medications to pregnant patients for tobacco
cessation?
46.6%53.4%
0%10%20%30%40%50%60%70%80%90%
100%
Yes No
Which medications do you prescribe to pregnant patients for tobacco
cessation?
35.6%
21.9%
41.1%
6.8% 5.5%
34.2%
13.7%
1.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Gum Lozenge Patch Nasal Inhaler Inhaler Bupropion Varenicline Other Med
Conclusions of Study
• Most North Dakota OB/GYN providers are aware of Tobacco Cessation resources available to their patients who smoke
• Most North Dakota OB/GYN providers offer Tobacco Cessation to their pregnant patients who use tobacco
• Review of medication use for Tobacco Cessation in pregnant patients
Why Tobacco Cessation?
• Benefits in pregnancy and long term health• Reduce Cardiovascular Complications• Reduce Lung Disease• Reduce Cancer• Reduce Type 2 Diabetes• Economic benefit for individual and society
Smoking in Pregnancy
• Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11%
• Smokers tend to be from lower socioeconomic and educational classes
• WIC smoking population as high as 40%+ in North Dakota North Dakota Department of Health
Smoking in Pregnancy
• ~75% of pregnant smokers desire quitting
• ~25-30% actually quit during pregnancy
• ~50% resume after pregnancy
• Smoking Cessation is most successful prior to pregnancy
Ruggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.
Complications of Smoking in Pregnancy
• Fourfold increase in small for gestational age; Increased prematurity
• Twice the rate of spontaneous abortions• Increased risk of abruptio placentae,
placenta previa, premature and prolonged rupture of membranes
Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 George L, et al Epidemiology. 2006 Sep;17(5):500-5Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003
Complications of Smoking in Pregnancy
• Intrauterine growth restriction• Stillbirth• Ectopic pregnancy• Infertility• Poor wound healing/surgical outcomes
Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.
Fetal/Child Effects of Maternal Smoking in
Pregnancy• Sudden infant death syndrome (SIDS) and
increased respiratory illnesses in children • Possible Association with maternal
smoking and ADHD/Behavioral Disorders• Congenital Anomalies (i.e., cleft lip/palate,
cardiac)Linnett KM, et al Pediatrics 2005; 116: 462-467Malik S, et al Pediatrics 2008 Apr;121(4):e810-6Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90
Issues in Smoking Cessation
• Triggers• Mood changes• Withdrawal symptoms (most smokers
underestimate)• Weight gain• Lack of support• Exposure to other smokers
Smoking Cessation Interventions in Pregnancy
• Brief Office Counseling• Smoking Cessation Class (i.e., Public
Health)• Third Party Payer programs• Quitlines• Online programs (i.e., Quitnet)• Pharmacologic
Smoking Cessation Interventions in Pregnancy
• 5 A’s• ASK about tobacco use (Tobacco as
a vital sign)• ADVISE to quit• ASSESS willingness to make a quit attempt• ASSIST
• those who are ready, with appropriate treatment• those who are not ready, with motivational counseling
• ARRANGE for follow-up
USPHS 2008
• Pregnancy affords a great opportunity
• Multiple short term followup clinic visits
• Phone calls/e-mail/quitline/quitnet
• ASK every time
• Options every time
Smoking Cessation Interventions in Pregnancy
Pharmacotherapy
Pharmacotherapy• Nicotine replacement therapy (NRT)
– Gum– Patch– Spray– Inhaler– Lozenge
• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • All are first line non-pregnant USPHS 2008
Pharmacotherapy for Pregnant Smokers
• NRT- Category D. Secreted in breast milk. Crosses placenta
• Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester?
• Varenicline (Chantix)- No data (yet)
Oncken CA, Kranzler HR Nic Tob Res Nov 2009
Pharmacotherapy for Pregnant Smokers
• USPHS 2008 more limited recommendations vs USPHS 2000
• ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail
Nicotine Replacement Therapy in Pregnancy
• 6 randomized controlled trials 2000-2010
• 5 show possible benefit
• Higher birth weight in 1 trial
• Multimodal treatment-benefit?Oncken, C et al Obstetrics & Gynecology, 112(4), 859-867.Pollak, KI et al. American Journal ofPreventive Medicine, 33(4), 297-305.Hotham ED et al Addictive Behaviors, 31, 641-648.Hegaard HK et al Acta Obstetricia et Gynecologica Scandinavica,82, 813-819.Kapur, B, et al Current Therapeutic Research, 62(4), 274-278.Wisborg, K, et al Obstetrics & Gynecology, 96(6), 967-971.
Pharmacotherapy for Pregnant Smokers
• NRT use must be risk vs benefit
-heavy smoker, relapsers, other risk ? (i.e. CVD risk factors)
-if NRT used, intermittent (gum, lozenge)
-higher birth weight?• Buproprion? 1 study shows benefit *• Varenciline- not recommended presently
*Chan B et al J Add Dis (24) 19-23 2005
Pharmacotherapy for Pregnant Smokers
• Smoking, Nicotine, and Pregnancy Trial
• Currently underway (UK study)
• Projected publication is 2013
Behavioral Interventions
In Office Counseling
• Brief
• No additional cost
• Slightly increases quit rates in non-pregnant adults
Classes
• Maybe difficult to access in rural areas (variable)
• Availability• Public Health, American Lung Association,
Employers• Sometimes cost• Effective
Quitlines
• Free• Widely available• Effective • ND Quitline ~30% 13 month quitrate in
general population• ND Quitline Free NRT for qualifying• MN Quitplan
Online Services
• Third party payers
• ND Quitnet: Premium content to ND residents, launched Feb 2010
• ND Quitnet Free NRT
nd.quitnet.com
Free to all North Dakota ResidentsFree NRT for qualifying
1-800-784-8669
Quitlines
• Other surrounding states have quitlines
• 1-800-QUITNOW is universal in U.S.
• Third Party Payers, Health Care Systems
Nicotine Addiction
• Smokers are addicts……………..• Nicotine is a highly addictive substance….• Successful treatment is based on addiction
treatment principles……• Behavioral/Cognitive/Motivational
Interviewing• Pharmacotherapy (when appropriate)
Challenges for Long-Term Tobacco Cessation
• Pregnant smokers tend to not be “committed quitters”
• Limitations of medication prescribing for pregnant/lactating smokers
• Smoking is nicotine addiction, not just a bad habit
Summary
• Smoking is problematic in pregnancy
• Long Term Health issues- mother and baby
• Nonpharmacologic resources first line for most pregnant smokers
• Possible limited role for NRT in select patients
Review Articles
• Crawford J, et al Smoking Cessation in Pregnancy: Why, How, and What Next Clinical Obstetrics &Gynecology June 2008
• Oncken CA, Kranzler HR What do we know about the role of pharmacotherapy for smoking cessation before or during pregnancy
Nicotine Tob Res. Nov 2009
See/Download My Slides:
• http://www.med.und.edu/familymedicine/slidedecks.html
Contact me:
701 777 3811 or 701 795 2861
Acknowledgements
• Dr. Charles Christianson, NORTHSTAR, UNDSMHS
• Jessica Behm, NORTHSTAR, UNDSMHS• North Dakota Chapter of the American College
of Obstetrics and Gynecology• North Dakota Department of Health, Division of
Tobacco Prevention and Control
