Transcript SMOKING CESSATION

Smoking Cessation in
Pregnancy
Richard O. Davis, MD
Department of OB/GYN
Division Maternal Fetal Medicine
University of Alabama at Birmingham
Objectives

Discuss the adverse outcomes related to smoking in
general

Discuss the adverse outcomes related to smoking
during pregnancy

Discuss benefits of smoking cessation during
pregnancy

Discuss methods to achieve smoking cessation during
pregnancy

Discuss relapse rates and potential avenues of
decreasing relapse
The Culprit
“Nicotina Tobacum”
- “Discovered” by Columbus on trips to
New World
- Became widely popular in western
Europe
- Initially popular in snuff and cigars
- Manufactured cigarette in 20th Century
increased smoking
The Facts
Tobacco Related Disease (TRD)

21% of American adults smoke
(44.5 million)

Each year, 440,000 Americans
die of TRD
Accounts for 1 in every 5 deaths

Ann Int Medicine 2006;145:839-44
The Facts
Smoking

Increased cardiovascular disease

Increased lung cancer
– 68,000 women die annually
– Responsible for 1 in 4 cancer deaths in
women
– 27,000 more deaths each year than
breast cancer
Public Health Service, Office of
Surgeon General 2001
The Facts
Initiation of Smoking

Begins early during teenage years

22% of U.S. high school students smoke

Historically, male smoking rates greater
than female

In many countries, no sex difference in
smoking rates
Lancet 2006;367:749-53
Women Who Smoke

High parity

Lesser education

Low economic status

Poor coping skills

Exposure to domestic violence

Job strain
Cultural Influence
Women Who Smoke
Native American/Alaskan
White (Non-Hispanic)
Black (Non-Hispanic)
Other
Asian
29%
20%
17%
18%
5%
MMWR 2004;53:427-51
The Facts
Complications in Pregnancy

Increased risk of ectopic pregnancy

Placenta previa

Placenta abruption

Stillbirth

Premature rupture of membranes
Clin Obstet Gynecol 2008;51(2):419-35
Complications in Pregnancy
The Likely Culprits

Nicotine: vasoconstriction
– Fetal serum (15%) and amniotic fluid levels
(88%) higher than maternal

Carbon Monoxide: Diminished tissue
oxygenation
– Fetal levels higher (15%) than maternal

Cyanide: Harmful to rapidly dividing cells
– Cyanide levels are higher in smokers
Clin Obstet Gynecol 2008;51(2):419-35
Complications in Pregnancy
Other Toxic Compounds

Ammonia

Polycyclic aromatic hydrocarbons

Vinyl chloride

Nitrogen oxide
Complications in Pregnancy
(Heavy Smoking > 20 cigarettes/day)

Low birthweight (<2500 g) ( 200-300 g)
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Preterm birth (OR 1.2 – 1.8)

Smoking accounts for 5% of prenatal
deaths and 20-30% of low birthweight
deliveries
Clin Obstet Gynecol 2008;51(2):419-35
Maternal Life Time Smoking
Complications

Atherosclerotic disease

Lung cancer

COPD

Increased risk of ectopic pregnancy

Premature menopause

Infertility

Osteoporosis
Infants, Children and Secondhand Smoke
Increased Risks

Respiratory infections

SIDS

Asthma/bronchitis

Short stature

Hyperactivity

Decreased school performance
Clin Obstet Gynecol 2008;51(2):419-35
Smoking Cessation Interventions

Higher proportion of women stop during
pregnancy than at any other time in their lives

20-30% of smoking women attempt to stop

About 40% who stop do so before their first OB
visit

Factors: Concern for effects on baby; nausea and
vomiting
Cochrane Database Sys Rev 2005
Challenges and Barriers to
Cessation
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Need to be acknowledged by patient and provider
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Most smokers make several attempts to quit
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Discuss reasons for past failures
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Successful smoking cessation is associated with
continuous patient education and assessment

The 5 A’s and 5 R’s (endorsed by ACOG and National
Cancer Institute and British Thoracic Society) for patients
unable or reluctant to quit
Clin Obstet Gynecol 2008;51(2):419-35
The 5 A’s

Ask: Query with multiple choice questions, document
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Advise: Urge tobacco users to quit
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Assess: Determine willingness to quit
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Assist: Provide aid and choose quit date

Arrange: Provide follow-up contact. Congratulate
success. Consider referral or more intensive treatment
and potential pharmacotherapy
The 5 R’s

Relevance: Identify motivational factors

Risk: Stress the acute and long-term risks of
smoking

Reward: Ask/Help patient identify benefits to her
and her family

Road blocks: Identify barriers and impediments

Repetition: Repeat motivational intervention and
visit
Smoking Cessation Intervention
Why During Pregnancy?

Genuine concern for baby
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Frequent physician/provider visits
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Only time some women seek medical care

Likely to experience high levels of social
and family support for quitting
Smoking Cessation Programs
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Shown to be helpful compared with no
intervention

Tobacco dependence treatments are
clinically useful and cost effective
Cochrane Database Sys Rev 2005
JAMA 2000;283:3244-254
Successful Smoking Cessation

Prevent up to 5% of perinatal deaths

Prevent up to 20-30% of low birthweight
births

Prevent up to 15% of preterm births
Am J Obstet Gynecol 2005;192:1856-1862
Smoking Cessation in Pregnancy

Smoking has greatest impact in third trimester

Encourage smoking cessation throughout
pregnancy

Women who quit by third trimester have
birthweights similar to non-smokers
Am J Public Health 1994;84:1127
Role of Counseling
Meta Analysis

Brief, intense counseling 5-15 minutes
– Cessation rate 5%-10%

Brief counseling and pregnancy specific
educational printed material
– Cessation doubles to about 20%
Cost Effectiveness of Smoking
Cessation

For every $1 for successful cessation, $3.3 are saved on
treating shorten neonatal morbidities (NICU)

Ratio of savings increase to 6:1 when long-term care
and morbidity are considered

Until further evidence based conclusions are made, brief
cognitive behavioral interventions accompanied by
pregnancy-specific self-help materials are most effective
intervention for pregnant smokers.
Individual Counseling for Smoking Cessation
Cochrane Database Sys Rev 2005
Nicotine Replacement Therapy

RCT by Wisborg et al showed that nicotine patches did
not affect cessation rate, but did increase BW
– Under-powered
– Low compliance

RCT by Oncken et al demonstrated that nicotine gum
had no effect on cessation rate
– Significantly reduced smoking
– Increased EGA and BW at delivery

Pollak et al showed NRT increased cessation rate by 3fold, but there was increased adverse outcomes in this
group
Wisborg et al. 2000. Obstet Gynecol 96:967-971.
Oncken et al. 2009. Obstet Gynecol 112:859-867.
Pollack et al. 2007. Am J Prev Med 33:297-305.
Bupropion
• Aminoketone that is a weak reuptake inhibitor of dopamine,
norepinephrine, and serotonin initially utilized as an
antidepressant
• In non-pregnant adults, multiple studies have shown that
bupropion significantly improves smoking cessation rates
• Case-control study including ~6K in each group by Alwan et al
showed infants with cardiac defects were more likely to have
been exposed to bupropion than controls (AOR 2.6; 95% CI 1.25.7)
• 3 other studies showed no associationHurt et al 1997. NEJM 337:1195-1202
Alwan et al 2010. Am J Obstet Gynecol 203:52e.1-6.
Chun-Fai-Chan B et al 2005. Am J Obstet Gynecol 192:932-6.
U.S. Department of Health and Human Services
Clinical Guidelines 2008
• Pregnant women should be actively counseled
and provided information regarding benefits of
smoking cessation
• Smoking cessation in early pregnancy is
preferred, but cessation at any time is beneficial
U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality (AHRQ)
Treating Tobacco Use and Dependence: 2008 Update
• No recommendation regarding medication use
during pregnancy
• NRT is probably safer than nicotine exposure from
cigarettes
• Inconclusive evidence that cessation medications
boost abstinence rates in pregnant smokers
Postpartum Period and Relapse
• 50%-90% relapse within first year after delivery
• No proven strategies to prevent relapse
• Continue encouragement, enforce benefits of
cessation, reinforce patient’s desire to be a good
mother