Smoking in Pregnancy and After, Secondhand Smoke Exposure in Infants and Children

1. Smoking in Pregnancy and After, Secondhand Smoke Exposure in Infants and Children Tom Peterson, MD, FAAP Vice President, Patient Safety SCL Health System

2. No Conflicts of Interest

3. Objectives • How to manage smoking during pregnancy, and after • How to prevent secondhand and thirdhand smoke exposure to infants • Strategies to ask about tobacco use and advise to quit in a non confrontational manner • The importance of a smoke-free home and smoke-free policies • How to refer clients and their families to 1-800-QUIT-NOW

4. High Personal and Societal Cost • Number one preventable cause of death in the US • 1 in 5 deaths are attributed to tobacco • Heart Disease, Cancer, Stroke, and COPD are the four leading causes of death in Michigan and US and all associated with smoking • 400,000 deaths attributed to smoking, annually • Second hand smoke is the fourth leading preventable cause of death • Enormous health care cost - $194 billion • Direct medical cost • Indirect cost – lost productivity and earnings • Medicaid cost – around 30.9 billion • Medicare cost – around 27.4 billion

5. People Quickly Forget…… Before the smoke-free policies and new laws in 1990’s began: • People could smoke almost anywhere: at work, on airplanes, in restaurants and in hospitals. • New moms smoked in post partum rooms while breast feeding • Teachers could smoke in hallways between classes, and schools often had smoking areas for students. • A majority of smokers would smoke in their homes and around their children. • The only "no smoking" signs were warnings near gas pumps or oxygen tanks. • Tobacco billboards were everywhere, including near schools and parks. • Anyone could buy cigarettes from vending machines, regardless of age

7. Smoking during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes. It is associated with 5 percent of infant deaths, 10 of preterm births, and 30 percent of small for gestational age infants. Heffner, Obst Gynec, 1993, 81:750 MMWR, 2009, 58:1

8. Smoking Mortality in Women Summary • 3 million mothers, daughters, wives, aunts, sisters, and grandmothers have died prematurely from smoking-related causes since 1980. • 2.1 million years of life each year are lost due to premature deaths. • 21 million years of life are cut short every 10 years. Source: Women and Smoking: A Report of the Surgeon General—2001

9. Smoking and Pregnancy Risks • Delayed conception • Premature ROM • Small for gestational age, loss of an average of 8 oz • SIDS • Abruptio placenta • Pre term birth • Greater chance of genetic defects, such as cleft palate or cleft lip • Placenta previa • Increased perinatal mortality • Smoking is believed to be responsible for 115,000 miscarriages a year and 5,600 stillbirths All are improved if smoking is stopped during pregnancy ! Source: Women and Smoking: A Report of the Surgeon General—2001

10. Correlating low-birth weight (<2,500 g) with cigarettes smoked/day 35 30 25 LBW % 20 15 10 5 0 0 0-5 6-10 11-15 16-20 21-30 30+ Cigarettes per day Source: Adapted from Simpson WJ

11. Prenatal Exposure to Cigarettes Risks in Children • long-term physical and intellectual problems in children, respiratory diseases • ear infections • tuberculosis • food allergies • cancer • asthma • short stature and attention disorders

12. Prenatal exposure to cigarettes – Other risks • ADHD • Low sperm count in male infants, lower fertility for females • 53% higher rates of nicotine addiction by age 21 • Behavior problems • Retinal cancer –twice the rate • Optic nerve dysplasia • Oral cleft lip/palate • Post natal infections- almost 3 times the rate in preterms • 40% higher rates of infant mortality • Obesity and type 2 diabetes • Smaller brain growth • Abnormal lung development • Hearing loss • Nicotine withdrawal at birth, irritability

13. Smoking Prevalence in Pregnancy • 14% overall in 2009, 18% in Michigan • 38% in Chippewa County and 24% in Marquette County!! • Highest in women: • under age 25 • ≤12 years of education • single • low income • American Indian/Alaska Native and nonHispanic white

14. Smoking During Pregnancy by Race and Ethnicity Prevalence of smoking (%) Source: National Center for Health Statistics

15. Do parents just need more education?

16. Limiting Second Hand Smoke Exposure to Infants and Children

17. Many Children Are Exposed More than 30% of children live with at least one smoker Younger children spend most of their time with a parent; if that parent smokes, SHS exposure can be highly significant Exposures occur in the home, child care, car

18. Secondhand Smoke (SHS) Exposure As A Health Disparity • Who is exposed to SHS? • Overall, about 25% of US children • Children in low-income homes – as high as 79% • 12.3% in lowest income families ADMIT to in-home SHS exposure/ compared to 2.3% in highest income • At least 50% of African American children • More than 1/3 of children in low SES homes • Medicaid status independently associated with hair nicotine level in children (exposure measure)

19. Immediate Effects of SHS Exposure Decreased lung function Respiratory infections Asthma Ear infections Hearing loss in teens Meningitis, pneumonia Household fires

20. Background 18% of children ages 3-11 are regularly exposed to secondhand tobacco smoke (SHS) in the home 54% of children ages 3-11 had detectable cotinine levels in the 2007-2008 NHANES 19 million children ages 3-11 Increased conduct disorder and decreased antioxidant levels even at low levels of exposure

21. Population Attributable Risks Annually: 200,000 cases of childhood asthma 150,000-300,000 cases of lower respiratory illness 800,000 middle ear infections 25,000-72,000 low birth weight or preterm infants 430 cases of SIDS

22. Many Sources of Exposure Home Car Daycare Grandparents Non-custodial parents Friends Multiunit housing

23. What is Third-hand Smoke? • Third-hand smoke is the left-over contamination in a room/car/clothing that persists after the cigarette is extinguished • The condensate on the glass from a smoking chamber was used in one of the first studies linking smoking and cancer • Homes and cars in which people have smoked may smell of cigarettes for long periods

24. Effect of Cigarette Smoke on Indoor Air Quality …it takes TWO hours for the air quality to return to normal for levels of CO, fine particles and particulate aromatic hydrocarbons..

25. Tobacco-Free Homes are Protective Children and adolescents who live in tobacco-free homes are less likely to use tobacco Strict smoke free home rules encourage cessation among smoking members of household Home smoking bans reduce smoking rates and cigarette consumption among youth

26. Life Cycle of Opportunities Secondhand smoke exposure Parental cessation Community advocacy Prevent second hand smoke exposure Assist parent in quitting Prevent mother from relapse Identify risks Early intervention Childhood Infancy Adolescence Teen cessation Well and ill visits In utero Adulthood Prenatal education Pregnant teens Parental cessation Smoking outside Community involvement Arch Pediatr Adolesc Med. 1997

27. Similar to obesity, we are dealing with a process, not a cure. Assessing patients readiness to change and sustainability are the keys! Asking is the first step………..

28. 2 As and an R: ASK Ask about tobacco use and SHS exposure at every visit Make asking routine, consistent, and systematic Use standardized documentation Document as a “vital sign” Just asking can double quit attempts

29. 2 As and an R: ADVISE Strongly advise every tobacco user to quit, move closer to a ready stage Provide information about cessation to all tobacco users Strongly urge smoke free homes and cars Look for “teachable moments” Personalize health risks Document your advice

30. 2 As and an R: REFER To quit line, 1-800-QUIT-NOW To community and Internet resources Give every tobacco user something that contains information about quitting, the harms of tobacco use, etc. To Sault Tribe Nicotine Dependence Program (Sault Tribe healthcare providers)

31. Negotiation Over Time Even small doses of counseling can add up over time. A complete ban may not be a reasonable first step for some smoking parents: Negotiate small, acceptable steps with the parent Reinforce health benefits to the child of reducing smoke exposure

32. The Exposure Ladder Completely non-smoking family Complete smoking ban in house and cars Smoking always outside Smoking usually outside Smoking elsewhere in the house Smoking in the room

33. Motivational Interviewing Person-centered, directive method for enhancing motivation to change By exploring and resolving AMBIVALENCE “I want to quit smoking, but I like to smoke” Can be used in brief doses!

34. Understanding Tobacco Addiction

35. Smokers Want to Quit 70% of tobacco users report wanting to quit Most have made at least one quit attempt Cite health expert advice as important Regardless of type! THIS MEANS YOU!

36. Tobacco Dependence: A Chronic Disease Similar to diabetes, heart failure, hypertension, hyperlipidemia: • Expectation for remission and relapse • Provide ongoing treatment: • advice/counseling • support • appropriate pharmacotherapy • There is a spectrum of disease severity • Effective treatments are available • High dose and multi-drug regimens may be necessary to achieve the target goals • May require referral to specialists • Individualized therapy and self management are key

37. First, Understand the Pregnant Smoker • 14%% smoking prevalence, up to 35% in medicaid population • Highest quit rate of all populations, most spontaneous quitters • 40-65% of moms quit on their own before even receiving prenatal care, but increasing relapse occurs by 6 months post partum, almost 80% relapse by 1 year • Many moms quit to minimize risk to baby, but have developed no coping mechanisms for preventing relapse after baby is born “6 month honeymoon” Ershoff,D Nic Tobacco Res, vol 6; April,2004

38. Cessation Programs—Pregnancy • Women quit smoking at higher rates during pregnancy than at any other time. • One-third of those who stop smoking during pregnancy are still smoke free one year after delivery. • Pregnancy cessation programs are cost-effective and beneficial to infant health—with the added value of improving overall cessation rates. Source: Women and Smoking: A Report of the Surgeon General—2001

39. Cessation 101 • Ask at every visit • Advise strongly to quit, regardless of stage of readiness • Use the new baby as a motivator • If ready: Set a quit date Refer to counseling (quitline) Brief discussion of relapse risks Arrange social support Follow up, and ask at every next check up

40. 2008 USDHHS Recommendations • Combination therapy of NRT patch and gum is a very effective treatment method • Evidence does not exist for medication use in pregnant women, adolescents, light smokers, or smoke-less tobacco users • Medication + counseling are best • Use of NRT in pre-contemplators increases quit attempts and rates • More counseling (6-8 sessions) is best

41. Pregnancy and Medications • Safety to mother and fetus of nicotine replacement still questioned • Counseling is the safest and most effective method • Medication most likely less dangerous in late pregnancy • Strong evidence of effectiveness in pregnancy lacks due to 2008 guidelines

42. Keeping Mothers From Relapsing After Birth • Lessen exposure to second hand smoke • Improve overall health of mother • Lessen likelihood of child smoking as a teenager • Minimize reproductive complications for future pregnancy’s • Women living with a smoker are 3 times more likely to relapse, resuming use of alcohol and coffee also increase relapse rates

43. Intervention and the ProviderEvery patient, every provider

44. You would not let a patient with heart disease or diabetes leave your office without being treated. Yet everyday, providers in California fail to treat their patients who smoke.

45. Why Don’t Providers Intervene More? • Inadequate training • Inadequate reimbursement • Not enough time • Not cost effective • Don’t know how • Not a priority for practice • Could alienate the parent/patient

46. Understanding The Adult Smoker • 70+% want to quit • A parent/patient is not alienated if appropriate approach is taken • 7 out of 10 attempt to quit every year • Between 8-9 quit attempts are needed for success • Tailor approach of advise and assistance to stage of readiness and level of interest (2 A’s and R)

47. Who is Ready? • Pre-contemplation – 40% • Contemplation – 40% • Action/Preparation – 20%

48. Guidelines for pharmacotherapy • Seven first line FDA approved pharmacotherapies • Bupropion SR • Chantix (Varenicline) • Nicotine Gum • Nicotine Inhaler • Nicotine Nasal Spray • Nicotine Patch • Nicotine Lozengers

49. Combination Options • Patch + gum • Patch + lozenge • Patch + nasal spray/inhaler • Bupropion + patch • Bupropion + gum

50. 2008 Recommendations: Meta-analysis of Most Effective Medications