Smoking Cessation in Pregnancy

1. Smoke-Free Families National Program Office 1 Smoking Cessation in Pregnancy Sharon Phelan MD University of New Mexico This presentation is based on recommendations of a number of organizations with an interest in improving maternal, infant and child health by reducing cigarette smoking during and after pregnancy.This presentation is based on recommendations of a number of organizations with an interest in improving maternal, infant and child health by reducing cigarette smoking during and after pregnancy.

2. Smoke-Free Families National Program Office 2 Impact of Smoking Kills >400,000 in US each year Related to 20% of deaths in US Causes lung cancer, other cancers, heart disease, stroke, pulmonary diseases Additive/chronic disease Unique issues with reproductive ability & obstetric complications for women

3. Smoke-Free Families National Program Office 3 Smoking Prevalence in the USA In the U.S., smoking among men has decreased substantially over the last 40 years; however, it has remained relatively stable among women.In the U.S., smoking among men has decreased substantially over the last 40 years; however, it has remained relatively stable among women.

4. Smoke-Free Families National Program Office 4 U.S. Demographics of the Female Smoker 22 million adult women smoke 1.5 million female adolescents smoke The earlier woman starts, the more likely she will be a heavy smoker as an adult over 500,000 female start smoking each year with 85-90% of those being teens Use typically begins by age 16; and almost certainly by 21.

5. Smoke-Free Families National Program Office 5 142,000 Deaths Attributable to Cigarette Smoking in Women - United States, 1990 Cigarette smoking is responsible for 140,000 or more deaths to women every year. These deaths are predominantly due to lung cancer, heart disease, chronic lung disease and stroke.Cigarette smoking is responsible for 140,000 or more deaths to women every year. These deaths are predominantly due to lung cancer, heart disease, chronic lung disease and stroke.

6. Smoke-Free Families National Program Office 6 The Role of Advertisement in Smoking among Women You have come a long way baby!

7. Smoke-Free Families National Program Office 7 Smoking before Pregnancy Decreased ovulation Impaired tubal transport The greater the number of cigarettes smoked, the greater the effect on fertility Although most women who smoke conceive, smoking is associated with reduced fertility in both men and women. The more either partner smokes, the greater the reduction in fertility. Although most women who smoke conceive, smoking is associated with reduced fertility in both men and women. The more either partner smokes, the greater the reduction in fertility.

8. Smoke-Free Families National Program Office 8 Smoking during PregnancyAdverse Outcomes Preterm birth Growth retardation Low birthweight Sudden Infant Death Syndrome (SIDS) Childhood illness School problems This slide lists the adverse outcomes which have been associated with smoking during pregnancy.This slide lists the adverse outcomes which have been associated with smoking during pregnancy.

9. Smoke-Free Families National Program Office 9 Smoking during PregnancyPregnancy Outcomes Outcome Effect Mean Gestational Age Little or None Preterm Birth RR = 1.4 Growth Retardation RR = 2.4Mean Birth weight - 149 grams A small proportion of preterm births, but 36% of all growth retardation is attributable to smoking. Smoking has a small but consistent effect on preterm birth, but a major impact on the size of the baby at birth. Most studies confirm that the babies of women who smoke weigh 150 to 200 gm (nearly half a pound) less than other babies.Smoking has a small but consistent effect on preterm birth, but a major impact on the size of the baby at birth. Most studies confirm that the babies of women who smoke weigh 150 to 200 gm (nearly half a pound) less than other babies.

10. Smoke-Free Families National Program Office 10 Smoking during Pregnancy Growth Retardation in Developed Countries-- Risk Factors In this meta-analysis which focused on risk for growth retardation in developed countries, cigarette smoking was responsible for more than a third of all cases of intrauterine growth retardation.In this meta-analysis which focused on risk for growth retardation in developed countries, cigarette smoking was responsible for more than a third of all cases of intrauterine growth retardation.

11. Smoke-Free Families National Program Office 11 Smoking during PregnancyReasons for Reduced Fetal Growth Lower maternal weight gain Vasoconstriction and decreased uterine blood flow Carbon monoxide toxicity Increased cyanide production Smoking reduces fetal growth through a number of mechanisms, but the most important is probably the effect of nicotine on blood flow to the fetus.Smoking reduces fetal growth through a number of mechanisms, but the most important is probably the effect of nicotine on blood flow to the fetus.

12. Smoke-Free Families National Program Office 12 Smoking during PregnancyPassive Exposure Maternal exposure to passive smoking in early pregnancy more than doubles the risk of delivering a small-for-gestational-age infant. Several studies show that even exposing the mothers to passive smoking will reduce the growth of her fetus. This study showed that maternal exposure to passive cigarette smoke doubled the risk of the infant being growth retarded.Several studies show that even exposing the mothers to passive smoking will reduce the growth of her fetus. This study showed that maternal exposure to passive cigarette smoke doubled the risk of the infant being growth retarded.

13. Smoke-Free Families National Program Office 13 Smoking after Pregnancy Children of smokers are more likely to experience: Sudden Infant Death Syndrome (SIDS) Respiratory infection including bronchitis and pneumonia Otitis media Asthma Hospitalization Children of smokers are more likely to experience a number of specific illnesses and conditions than the children of non-smokers.Children of smokers are more likely to experience a number of specific illnesses and conditions than the children of non-smokers.

14. Smoke-Free Families National Program Office 14 Risk Factors For Smoking Low Education (< HS 44%) Young Age White Race (17% smoke in Pg) Medicaid Recipient (60% smokers are medicaid Partner Who Smokes Overall, women with any of these 5 characteristics are more likely to smoke.Overall, women with any of these 5 characteristics are more likely to smoke.

15. Smoke-Free Families National Program Office 15 Smoking in Grade SchoolUSA 1975-1996 Of real concern is the recent rise in smoking among high school students.Of real concern is the recent rise in smoking among high school students.

16. Smoke-Free Families National Program Office 16 Smoking Among Pregnant Women United States, 1965-1996 Reported smoking among pregnant women has declined slightly in recent years. However, because of a potential increase in deception among pregnant smokers, estimated to be as high as 30-50% in some studies, the extent of the decline is unknown.Reported smoking among pregnant women has declined slightly in recent years. However, because of a potential increase in deception among pregnant smokers, estimated to be as high as 30-50% in some studies, the extent of the decline is unknown.

17. Smoke-Free Families National Program Office 17 Smoking during Pregnancy By Race and Ethnicity United States, 1996 Rates of cigarette smoking vary considerably by race and ethnic origin. These figures are based on self-reports and would probably be higher if a biochemical test of smoking were used.Rates of cigarette smoking vary considerably by race and ethnic origin. These figures are based on self-reports and would probably be higher if a biochemical test of smoking were used.

18. Smoke-Free Families National Program Office 18 Smoking during PregnancyBy Employment Status Women with the highest level jobs tend to smoke the least.Women with the highest level jobs tend to smoke the least.

19. Smoke-Free Families National Program Office 19 Smoking Cessation During PregnancyCurrent PracticeACOG Survey Discuss adverse effects 94% Advise to stop smoking 93% Advise to “cut down” 78% Assist in planning 56% Provide self-help materials 35% Refer 20% Many different methods have been used to train providers to do smoking cessation counseling in pregnancy. To be able to perform the 5-15 minute counseling program, about 3 hours in training time is required. This training may be provided by a self-instructional manual or an on-line computer-based training program. Many different methods have been used to train providers to do smoking cessation counseling in pregnancy. To be able to perform the 5-15 minute counseling program, about 3 hours in training time is required. This training may be provided by a self-instructional manual or an on-line computer-based training program.

20. Smoke-Free Families National Program Office 20 Current Barriers Other than advice to quit, most obstetric providers do not include smoking cessation counseling among their services because: They question the effectiveness of counseling There are no specific ACOG recommendations Their staffs are untrained in this area There are too many intervention choices There is no reimbursement for counseling The reasons why a smoking cessation program is not offered to pregnant women are not altogether clear. However, the fact that major organizations have not adopted a specific program, that providers are often not convinced that any intervention works, that providers are often not trained, and that there is no reimbursement, all work together to influence providers not to initiate a smoking cessation program.The reasons why a smoking cessation program is not offered to pregnant women are not altogether clear. However, the fact that major organizations have not adopted a specific program, that providers are often not convinced that any intervention works, that providers are often not trained, and that there is no reimbursement, all work together to influence providers not to initiate a smoking cessation program.

21. Smoke-Free Families National Program Office 21 Best Practice This simple “best practice” intervention is: Science-based Doable in an office setting Relatively inexpensive Likely to have an immediate impact More extensive interventions achieve little additional benefit. The print materials should provide these components and also should be compatible with the counseling message.The print materials should provide these components and also should be compatible with the counseling message.

22. Smoke-Free Families National Program Office 22 Smoking Cessation during PregnancyBest Clinical Practice Meta-analyses reviewing smoking cessation studies have concluded that: For women smoking at the first prenatal visit, the provision of a single 5-15 minute counseling session by a trained provider plus appropriate print materials can increase cessation rates from 5-10% to  15-20%. In the last several years, it has become clear that one type of intervention significantly reduces smoking in pregnancy. For those pregnant women still smoking, a 5-15 minute counseling session by a trained provider plus appropriate print materials tailored for pregnancy will achieve a substantial additional increase in smoking cessation.In the last several years, it has become clear that one type of intervention significantly reduces smoking in pregnancy. For those pregnant women still smoking, a 5-15 minute counseling session by a trained provider plus appropriate print materials tailored for pregnancy will achieve a substantial additional increase in smoking cessation.

23. Smoke-Free Families National Program Office 23 The Five A’s from NCI Ask Assess Past and current level of smoking Current stage in quitting process Advise/Educate Clear message to quit and the benefits Assist - through the stages of change Arrange Follow-up - what ever stage

24. Smoke-Free Families National Program Office 24 Recommended Multiple-Choice Question Which of the following statements best describes your cigarette smoking? Would you say: 1. I smoke regularly now -- about the same amount as before finding out I was pregnant. 2. I smoke regularly now, but I’ve cut down since I found out I was pregnant. 3. I smoke every once in a while. 4. I have quit smoking since finding out I was pregnant. 5. I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes. Using a structured multiple choice question such as this one reduces deception compared to simply asking whether or not the woman smokes.Using a structured multiple choice question such as this one reduces deception compared to simply asking whether or not the woman smokes.

25. Smoke-Free Families National Program Office 25 Spontaneous Cessation Between 10 and 40% of pregnant smokers quit spontaneously. The percentage depends on the mother’s age, race, education, duration and level of smoking. Spontaneous cessation by the woman just before or early in pregnancy plays an important role in reducing smoking during pregnancy and in improving pregnancy outcomes.Spontaneous cessation by the woman just before or early in pregnancy plays an important role in reducing smoking during pregnancy and in improving pregnancy outcomes.

26. Smoke-Free Families National Program Office 26 Spontaneous Quitters Are less addicted Appear to be more concerned about effect of smoking on baby Have more years of school These characteristics are associated with spontaneous cessation. More needs to be learned about how and why these women quit.These characteristics are associated with spontaneous cessation. More needs to be learned about how and why these women quit.

27. Smoke-Free Families National Program Office 27 ASSESS: Prior and current levels of smoking Assess the willingness of the patient to attempt to quit within 30 days

28. Smoke-Free Families National Program Office 28 ADVISE: Provide clear, strong advice to quit with personalized messages about the impact of smoking and quitting on the woman and her family

29. Smoke-Free Families National Program Office 29 ASSIST: Develop a quit plan including a quit date Review preparations for quitting Offer pharmaceutical therapy Provide educational materials Provide/refer to skills training and/or social support programs

30. Smoke-Free Families National Program Office 30 Preparations for Quitting Instruct patient to inform family, friends and co-workers of decision and request their support and understanding with no smoking around them. Instruct patient to remove cigarettes, ashtrays, and matches from home, car, office Ask patient to identify cues that trigger smoking and devise strategies to defuse them

31. Smoke-Free Families National Program Office 31 Preparations for Quitting Review previous attempts to quit and have patient identify what helped and what hurt Help patient anticipate challenges of nicotine withdrawal and stress, and discuss how to deal with them Discuss the likelihood of postcessation weight gain and how to deal with it.

32. Smoke-Free Families National Program Office 32 ARRANGE: Periodic follow up visits : first within 2 weeks, second within the month and subsequent as needed If abstaining: Praise and see how can help If relapsed: Ask for recommitment Remind patient we learn from our mistakes Id the problems and think about new approach

33. Smoke-Free Families National Program Office 33 Smoking Cessation during PregnancyPrint Materials Adverse effects of smoking on pregnancy Techniques to help quitting Benefits to be gained from quitting and for reducing smoking The print materials should provide these components and also should be compatible with the counseling message.The print materials should provide these components and also should be compatible with the counseling message.

34. Smoke-Free Families National Program Office 34 Implementing Cessation Programs in MCOs Develop administrative commitment Involve staff early in implementation planning Assign staff to monitor implementation Train clinical & support staff Adapt procedures to specific setting Evaluate and give feedback to staff Managed care organizations have often not adopted or effectively implemented smoking cessation programs during pregnancy. Successfully implementing such programs requires a great deal of effort and attention.Managed care organizations have often not adopted or effectively implemented smoking cessation programs during pregnancy. Successfully implementing such programs requires a great deal of effort and attention.

35. Smoke-Free Families National Program Office 35 Smoking Cessationduring Pregnancy The 5-15 minute counseling intervention has not significantly increased smoking cessation in heavy smokers. One group least likely to respond to the 5-15 minute intervention are women who smoke the most and have been smoking the longest. One group least likely to respond to the 5-15 minute intervention are women who smoke the most and have been smoking the longest.

36. Smoke-Free Families National Program Office 36 In non-pregnant smokers, both NRT (patch, gum, inhaler) and antidepressants (buproprion) approximately double cessation compared to behavioral methods. In very limited studies in pregnant women, NRT was not associated with adverse outcomes, but did have a short-term influence on fetal breathing movements and fetal heart rate variability. Pharmacology approaches work and are safe in non pregnant adults.Pharmacology approaches work and are safe in non pregnant adults.

37. Smoke-Free Families National Program Office 37 There are no existing studies in which the safety or efficacy of either antidepressants or NRT has occurred in a sufficiently large pregnant population to determine what might occur with large-scale use. Unfortunately, FDA-approved pharmacotherapies have not yet been shown to be safe or effective for use during pregnancy.Unfortunately, FDA-approved pharmacotherapies have not yet been shown to be safe or effective for use during pregnancy.

38. Smoke-Free Families National Program Office 38 Smoking Cessation during PregnancyPharmacologic Interventions Since the heaviest smokers do not appear to respond well to behavioral interventions used alone, the use of adjunctive pharmacologic approaches to achieve cessation in these women should be explored. The efficacy and safety of these pharmacological approaches during pregnancy is unknown. Pharmacologic interventions, if safe, are likely to achieve cessation in more heavy smokers than counseling alone. Studies to determine the effectiveness and safety of pharmacotherapeutic agents during pregnancy are indicated.Pharmacologic interventions, if safe, are likely to achieve cessation in more heavy smokers than counseling alone. Studies to determine the effectiveness and safety of pharmacotherapeutic agents during pregnancy are indicated.

39. Smoke-Free Families National Program Office 39 Postpartum Smoking Cessation About 35% of the women who stop smoking during pregnancy remain abstinent at least 6 months after delivery.About 35% of the women who stop smoking during pregnancy remain abstinent at least 6 months after delivery.

40. Smoke-Free Families National Program Office 40 Smoking Cessation during PregnancyPostpartum Maintenance Woman’s health Next pregnancy Child’s health This rate of smoking cessation maintained after pregnancy is higher than achieved in virtually all non-pregnant populations and should be looked upon as a success (up to 35% quit) rather than as a failure (65% return to smoking). Those women who remain quit will be healthier over their lifetimes, their children will be healthier, and in their next pregnancies, their fetuses will be healthier. This rate of smoking cessation maintained after pregnancy is higher than achieved in virtually all non-pregnant populations and should be looked upon as a success (up to 35% quit) rather than as a failure (65% return to smoking). Those women who remain quit will be healthier over their lifetimes, their children will be healthier, and in their next pregnancies, their fetuses will be healthier.

41. Smoke-Free Families National Program Office 41 Goal Achieve widest possible utilization by providers of an officially endorsed, pregnancy-specific, smoking cessation intervention Because of the potential benefit of cessation to pregnant smokers, and the increased cessation achieved by the right type of program, it is crucial that every pregnant smoker has access to effective smoking cessation support and assistance.Because of the potential benefit of cessation to pregnant smokers, and the increased cessation achieved by the right type of program, it is crucial that every pregnant smoker has access to effective smoking cessation support and assistance.