Smoking Cessation during Pregnancy and Lactation

1. Smoking Cessation during Pregnancy and Lactation Alice Ordean MD, CCFP, MHSc Medical Director, T-CUP, SJHC November 30, 2011

2. Outline • Prevalence of tobacco use during pregnancy • Effects: obstetrical, fetal, neonatal, adolescence • Screening and assessment for nicotine dependence • Smoking cessation interventions during pregnancy • Tools and resources

3. Prevalence of smoking during pregnancy • 22% of women report smoking in the 3 months prior to pregnancy or before becoming aware of pregnancy (16% smoking daily, 6% occasionally) • Proportion of women who smoked during pregnancy declined to ~11% in third trimester (7% smoked daily & 4% occasionally) • Proportion of daily smokers who smoked 10+ cig/day declined during pregnancy & increased again postpartum • Daily smokers in T3: 58% smoked 1-9 cig/day, 42% smoked >10 cig • 80% of women try to quit or reduce smoking Ref: Canadian Maternity Experiences Survey, 2009

4. Prevalence of smoking during pregnancy (2) • 47% of those who quit during pregnancy had resumed smoking by 6 months postpartum – overall 16% were smoking after delivery (12% daily, 4% occasionally) • During pregnancy, 23% of women lived with someone who smoked • Reasons for smoking postpartum: stress mgmt, time for herself, losing weight

5. Characteristics of women who smoke during pregnancy • Younger age: <24 years old • Educational level: less than high school education • Multiparity • Low socioeconomic status: Women living in a household at or below the low income cut-off • Marital status: single mothers • Variations by provinces & territories Ref: Canadian Maternity Experiences Survey, 2009

6. Pregnancy-related effects of maternal smoking Dose-response relationship documented: effects influenced by amount & duration of smoking Increased risk of : • Spontaneous abortion -1.5x, ectopic pregnancy • Intrauterine growth restriction (IUGR) – 2x • Preterm delivery, premature rupture of membranes • Placental complications (placenta previa, placental abruption) 2x • Infant morbidity & mortality (eg. stillbirth) mostly due to increased IUGR and preterm delivery Ref: www.pregnets.org

7. Breastfeeding • Products of tobacco smoke are concentrated in breast milk (up to 5x greater than in blood) • Smoking can decrease quality & quantity of breast milk by inhibiting milk let-down  feeding difficulties and early weaning from BF • Breastfeeding is protective against respiratory illnesses  BF is encouraged among smokers • Nicotine levels increase after smoking; half-life of nicotine is 95 minutes  women should avoid smoking just before and during feeding

8. Neonatal & Childhood effects Effects linked to maternal smoking during pregnancy and second-hand smoke exposure Increased risk of: • More cranky or colicky babies • Sudden infant death syndrome 2-5x • Respiratory illnesses eg. bronchitis, pneumonia • Asthma & allergies up to 400x • Middle ear infections • Neurodevelopmental (eg. poorer math & reading skills) & behavioural problems (eg. attention-deficit/hyperactivity disorder)

9. Table 1 – Negative Effects Associated with Cigarette Smoking During Pregnancy and Breastfeeding [1] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005

10. Reasons for Screening during Pregnancy • Cigarette smoking during pregnancy and breastfeeding is associated with numerous negative effects – preventable outcomes by cessation of smoking at any point during pregnancy • Pregnancy represents a window of opportunity to help woman make a change

11. Who is more likely to quit? Women with the following characteristics are more likely to quit smoking: • higher educated • lighter smokers • those who live with nonsmokers • those with stronger beliefs in the harms of smoking • those experiencing their first pregnancy

12. Practice Approaches – Engaging pregnant women • Woman-centred care: care focused on woman’s needs in context of social, economic life circumstances eg. Focus on woman’s health before and during pregnancy • Harm reduction: focus on reducing harm to woman & fetus from effects of smoking eg. Reduced smoking, nicotine replacement tx • Reducing stigma to help engage pregnant smokers: deal with pressures to quit smoking

13. Smoking Cessation Strategies in Pregnancy • Offer a variety of cessation approaches and intensities depending on stage of change • Address the postpartum period in the prenatal intervention • Build-in partner support • Encourage smoking reduction as an alternative to smoking cessation for those unable to quit

14. Screening ASK: “Do you smoke? How many cigarettes do you smoke?” • If she does not smoke, inquire about environmental tobacco exposure “Does anyone smoke around you or your children?” • If yes, then educate about ways to stop or decrease exposure to second hand smoke

15. Screening (2) Assess motivation/readiness to change behaviour • Ask: “How do you feel about your smoking? Are you planning to quit?” • “On a scale of 1-10 how would you rate your motivation to quit smoking at this time? • “On a scale of 1-10, how important is it for you to quit at this time?” • “On a scale of 1-10, how confident are you that you can quit smoking at this time?”

16. Relapse Progress STAGES OF CHANGE Precontemplation Contemplation Preparation Action Maintenance

17. Stages of Change Pre-contemplative: no interest in quitting, or “in more than 6 months” Contemplative: thinking about quitting in 1-6 months Preparation: planning to quit in next month Action stage: in process of cutting down or has set a quit date Maintenance: quit more than 6 months ago

18. Assessment • Amount & duration smoked (pack-years), pattern of smoking • Degree of dependence eg. Fagerstrom test – time from waking up to first cigarette • Reasons for smoking and for quitting • Past experience with quitting: what worked and what did not, relapse triggers • Other addictions, medical problems, psychiatric problems, medications

19. Smoking Cessation Management 1. Counselling: tailor intervention according to stage of change & focus on moving patients along stages of change and enhancing confidence to quit 2. Pharmacotherapy: suppress withdrawal symptoms & cravings • Nicotine replacement therapies • Bupropion (Zyban) • Varenicline (Champix)

20. Smoking Cessation Counselling • Smoking cessation should be encouraged for all pregnant, breastfeeding and postpartum women • A smoke-free home environment should also be encouraged to avoid exposure to second-hand smoke • Counselling is recommended as first line treatment for smoking cessation during pregnancy and breastfeeding (some evidence for increased quitting rates)

21. Goals of Counselling

22. Components of Counselling Interventions • Counselling: brief, delivered by range of practitioners; may be conducted by physicians, allied healthcare professionals (e.g. social worker, pharmacist), family home visitors, etc. • Quit guides: take-home, patient-focused guide to quitting • Buddy support: to provide social support • Partner counselling/social context • Education about pregnancy & smoking

23. Managing the Environment During Pregnancy • Make no-smoking rules for her home • Handling the challenge of partner smoking • Avoid triggers & remove “reminders” Postpartum • Explain to others that the same no-smoking rules apply as in pregnancy

24. Managing Cravings • Be aware of what’s happening: discuss what she enjoyed about smoking vs. non-smoking • Be prepared to resist it: change past routines • Remember that it will not last long • Use a non-smoking alternative whenever feel the need to smoke eg. exercising, chewing gum, eating, using relaxation skills & other enjoyable activities eg. phoning a friend • Avoid other substances eg. coffee, alcohol

25. Managing difficult situations (“slips”) • Assure patient that slips and relapses are normal: learning opportunity, not a failure • Identify triggers & develop a plan to cope with them • Maintain motivation and encourage positive self-talk to maintain self-confidence • Strengthen commitment • Get back on track

26. Partner/Family Involvement • Partners, friends & family members should also be offered smoking cessation interventions • Despite preliminary evidence that continued smoking and relapse are more likely among pregnant women who have a smoking partner, there is limited data regarding the benefits of partner involvement in smoking cessation interventions for pregnant smokers • In non-pregnant populations, interventions to increase support did not find increased quitting rates

27. Pharmacological Support Second-line treatment options during pregnancy may include: • Nicotine replacement therapies • Bupropion (Zyban) • Varenicline (Champix)

28. Nicotine Withdrawal • Symptoms increase by 3-4 days after quitting smoking and last for 1 week • First symptoms: dysphoric or depressed mood, irritability, restlessness, anxiety, insomnia, fatigue, increased appetite • Lack of concentration and cravings may last for months • Symptoms worse in heavy smokers and those who smoke within 30 minutes of getting up

29. Nicotine Replacement Therapies (NRT): Clinical Considerations • NRT can be considered as a second line option for individuals who cannot quit after counselling interventions • Intermittent dosing nicotine replacement therapies (such as lozenges/gum) are preferred over continuous dosing of a patch • There is limited evidence on harms associated with the use of nicotine replacement therapy (NRT) during pregnancy

30. NRT (2): Clinical Considerations • Evidence from RCTs failed to find a difference in smoking cessation rates, but there may be some decrease in number of cigarettes smoked per day & improved pregnancy outcomes (lower rates of preterm delivery & low birth weight) • Benefits of NRT seems to outweigh potential risks; therefore, NRT should be considered when counselling has been ineffective.

31. Bupropion (Zyban) • Depression during pregnancy is a common occurrence and the use of Zyban (bupropion) may be appropriate to treat both smoking and depression • There is limited evidence on the effectiveness of bupropion for smoking cessation during pregnancy; only 1 prospective study demonstrated increased quitting rates with bupropion use during pregnancy

32. Bupropion (2) • In addition, there is no evidence of harm related to the use of bupropion during pregnancy and therefore, it may be considered for use as an alternative to NRT for a subpopulation of pregnant smokers.

33. Varenicline (Champix) • No evidence regarding safety of varenicline during pregnancy; therefore, its use during pregnancy is not recommended.

34. Summary: 4 A’s

35. Provider Tools/Resources • PREGNETS www.pregnets.org [specialized toolkit to address smoking cessation among pregnant & postpartum women] • CAN-ADAPTT www.can-adaptt.net [evidence- based clinical practice guidelines] • TEACH (Training enhancement in applied cessation counselling and health)“Helping Pregnant Smokers Stop Smoking: An Interactive Case Based Course [evidence-based training and continuing professional education]

36. Patient Tools/Resources (2) • CAMH Nicotine Dependence Clinic www.camh.net • Ontario Smokers Helpline 1-877-513-5333 • Motherisk www.motherisk.org or 1-877-327-4636

37. CAN-ADAPTT • Clinical practice guideline & knowledge exchange network • Integrates practice, policy and research in a collaborative smoking cessation network • Goal: To inform the development of a Pan-Canadian clinical practice guideline (CPG) for smoking cessation Dr. Peter Selby, Principal Investigator, CAN-ADAPTT Funded by the Drugs and Tobacco Initiatives Program, Health Canada

38. Pregnant and Breastfeeding Women • Smoking cessation should be encouraged to all pregnant and breastfeeding women. (GRADE = 1A) • During pregnancy and breastfeeding, counselling is recommended as first line treatment for smoking cessation.  (GRADE = 1A) • If counselling is found ineffective, intermittent dosing nicotine replacement therapies (such as lozenges, gum) are preferred over continuous dosing of the patch after a risk-benefit analysis. (GRADE = 1C) • Partners, friends and family members should also be offered smoking cessation interventions. (GRADE = 2B) • A smoke-free home environment should be encouraged for pregnant and breastfeeding women to avoid exposure to second-hand smoke. (GRADE: 1B)

39. Durham Region Health Department provides a number of services to promote and support tobacco-free living • DRHD offers: • A 6-week Support Group for smokers that want to quit using tobacco • Telephone counselling • Quit Kits for prenatal and postpartum women that contain self-help materials • Information for new dads regarding quitting smoking and second-hand smoke • Assistance for health care providers to develop comprehensive tobacco cessation strategies for their setting • Information and resources regarding community supports available to facilitate tobacco cessation • Contact Durham Health Connection Line 905-666-6241 or 1-800-841-2729

40. HKPR District Health Unit Health Unit Actions: • Knowledge & skill training for all Chronic Disease & Family Health Department Staff • Implement 4A protocols • Information Request Line • Prenatal Programs • Healthy Babies Healthy Children • Post-partum Enhancement Program • Integrated into continuum of care for follow-up (family home visitors & family health nurses) • Focus on increasing access to cessation services by developing community capacity to provide brief interventions in a variety of settings

41. HKPR District Health Unit Partners with local health care professionals to: • Provide training & technical assistance to develop community capacity to provide interventions • Increase awareness of evidence-based cessation initiatives • Motivate local practitioners to implement evidence-based strategies (eg. 4A Protocol) • Increase the number of people contemplating, preparing & taking action to quit (particularly among youth, young men, & people with low SES)

42. Peterborough County-City Health Unit • One to one individual counselling appointments • Quit smoking groups • Telephone counselling • Provision of self-help resources Funded by Health Canada to March 2012

43. Peterborough County-City Health Unit • Support group for pregnant and post partum women who smoke • Facilitated by a Community Health Worker and Public Health Nurse • Free Childcare • Free transportation • $20 Gift card every week Funded by ECHO: Improving Women’s Health In Ontario to March 2013

44. The Canadian Cancer Society Smokers’ Helpline • Free, confidential phone, online and text messaging services at 1 877 513-5333 and SmokersHelpline.ca • English, French and interpreter service • Accept Fax Referrals from health care providers through Quit Connection program (www.smokershelpline.ca/refer) • Specialized protocols in place to serve pregnant and post-partum women Ann Burke 705-726-8032 ext. 3226 aburke2@ontario.cancer.ca

45. The Canadian Cancer Society Smokers’ HelplineWorking with pregnant and post-partum women • 7% of women age 20 to 44 years were pregnant or breast feeding at the time of their first contact with Smokers’ Helpline • Quit Coaches operate from a perspective that is woman-centred rather than fetus-centred • While we do not exclude concern for the fetus, the focus is on the woman’s health and goals. • Use Motivational interviewing to support an identity shift from smoker to non-smoker • Expanded proactive service offered, surrounding the due date • Can receive up to 14 proactive calls from a Quit Coach