Transcript Maternal & Child Health

Maternal & Child Health and Smoking
Your name, institution, etc. here
YOUR LOGO HERE
(can paste to each slide)
…dedicated to eliminating children’s exposure
to tobacco and secondhand smoke
Objectives
1)
Discuss fetal/newborn and maternal risks of maternal
tobacco use
2)
Identify who is at greater risk of smoking during pregnancy
and to identify some of the unique issues of pregnancy
3)
Acquire knowledge about pharmacotherapy and its role in
smoking cessation in pregnancy
4)
Provide a brief smoking cessation intervention during
pregnancy and post partum period
The Evidence Is Clear!
When a woman quits smoking during pregnancy,
her chances of having an uncomplicated pregnancy
and healthy baby are dramatically increased
Risks for Women Who Smoke
 Reproductive health
problems





Infertility
Conception delay
Pregnancy complications
Menstrual irregularity
Earlier menopause
 Compromised immune
system
 Respond differently to
nicotine
 Cancer
 Less likely to breast feed
 Osteoporosis
 Thrombosis with use of
oral contraceptives
Prenatal/Neonatal
Outcomes
 Miscarriage
 Fetal death
 Pre-term deliveries
 Low birth weight baby
 Ectopic pregnancies
 Placenta previa and placental
abruption
 SIDS
 Birth Defects (cleft lip/palate, heart
defects, webbing)
A Call to Action:
“Smoking is the most modifiable
risk factor for poor birth outcomes”
2008 CPG Recommendation
“Because of the serious risk of smoking to the pregnant
smoker and fetus, whenever possible smokers should
be offered person-to-person psychosocial
interventions that exceed minimal advice”
2008 CPG Recommendation
Although abstinence early in pregnancy will produce
greatest benefits to the fetus and expectant mother,
quitting at any point in pregnancy can yield benefits…
clinicians should offer effective interventions
at first prenatal visit as well a throughout the pregnancy
Intervention Makes a Difference
 Smoking cessation
intervention by clinicians
improves quit rates
 Brief counseling (5 to 15
minutes total) can help many
pregnant smokers quit
 A woman is more likely to
quit smoking during
pregnancy than at any other
time in her life
Smoke Free Families
 What we knew in 2000 has stood the test of time
 For light to moderate smokers, extended or augmented
counseling increases the likelihood of cessation
 The components of extended counseling are still supported
 Many enhancements have been tested but none have
produced results compelling enough to power a change in
recommendations
Teachable Moments Before, During
and Beyond Pregnancy
 Preconception Care
 All Gynecology and primary care visits
 Help her quit during pregnancy
 Never too late to quit
 Smoke free home and car during pregnancy
 Smoke free public places and work place
 Avoid secondhand smoke
 3rd trimester begin post partum discussion
 What are her intentions post partum?
Pregnancy:
A Unique Time
 Often more open to change
 May have more support to quit while pregnant
 May not be socially acceptable to smoke if pregnant
 Excited, ambivalent, afraid
 May have more stress if unplanned pregnancy
 May have added financial burden even if planned
Post Partum
Opportunities
 Prepare for post partum triggers, cues, depression
 Intervention during hospital stay
 Home visitors
 First pediatric appointment
 WIC
 Follow-up call by quit line or other counselors
 Post partum checkup
 Smoke free home and car
Counseling Intervention
5 As
A
A
sk about tobacco use
A
A
ssess willingness
A
rrange for follow-up
dvise to quit
ssist in quit attempt
R
efer
 Community
Resources
 1-800-QuitNOW
A
sk: About Tobacco Use
 Ask or verify responses in a non-judgmental way:
 Identify smoking status
 Counsel all smokers and recent quitters
 Ask about Household and work environment
 Discuss effects of SHS
 If they smoke assess
 Nicotine dependence
 Patterns of use
 Past quit attempts
Ask
Which of the following statements
best describes your cigarette smoking?
I have never
smoked or have
smoked fewer than
100 cigarettes in
my lifetime
I stopped smoking
before I found out I
was pregnant and
am not smoking
now
I stopped smoking
after I found out I
was pregnant and
am not smoking
now
Congratulate
patient
I smoke some now
but have cut down
since I found out I
am pregnant
I smoke about the
same amount now
as I did before I
found out I was
pregnant
Advise
A
ssess: Willingness to Make a
Quit Attempt
 Assess patient’s level of
interest in quitting and intention
to take action to quit
 Ask key questions
Importance and confidence scales
“On a scale from 1 to 10, how important is it to you to quit
smoking, where 1 is that it is not important at all and 10 is
that it is very important.”
1= not
important
10=very
important
Importance and confidence scales
“On a scale from 1 to 10, how confident are you that you could
quit if you tried?”
1= not
confident
10=very
confident
A
ssist: in Quit Attempt
Preparation Stage
(Willing to quit)
 Help the patient with a quit plan
 Provide practical counseling
 Provide social support
 Social support with treatment (Intra-treatment)
 Social support outside treatment (Extra-treatment)
Provide supplemental materials (Self-learning materials,
quitline, groups)
2008 CPG statement and pharmacotherapy in
pregnancy
Safety is not categorical. A designation of “safe” reflects a
conclusion that a drug’s safety outweigh its risks. Nicotine
most likely does have adverse effects on the fetus during
pregnancy.
Although the use of NRT exposes the pregnant women to
nicotine, smoking exposes them to nicotine plus numerous
that are injurious to the fetus other chemicals. These
concerns must be considered in the context of inconclusive
evidence that cessation medications boost abstinence
rates in pregnant women.
Pharmacotherapy and Pregnancy
“If the increased likelihood of smoking
cessation, with its potential benefits,
outweighs the unknown risk of nicotine
replacement and potential concomitant
smoking, nicotine replacement products or
other pharmaceuticals may be considered.”
Personalized Plan for
Patients
Note: Most materials available in Spanish
Patients Who Decline to Quit:
Using the 5 Rs
Relevance
Risks
Rewards
Roadblocks
Repetition
5 Rs: Relevance (importance)
 Ask patient to identify how quitting might be personally
relevant, such as:
Relevant to her as a women
Relevant to pregnancy
Relevant to unborn child
Relevant to baby after birth
Relevant to money
?
Pros and Cons
Good things about Smoking
vs
Bad Things about Smoking
Pros and Cons
Hard things about quitting
vs
Benefits of Quitting
5 Rs: Risks
 Ask, “What have you heard about smoking during
pregnancy?”
 Reiterate benefits for her unborn baby and her other
children
 Reiterate benefits to her
 Tell her that a previous trouble-free pregnancy is no
guarantee that this pregnancy will be the same
5 Rs : Rewards
 Your baby will get more oxygen after just 1 day
 Your clothes and hair will smell better
 You will have more money
 Food will taste better
 You will have more energy
 You will be healthier
5 Rs : Roadblocks
 Negative moods
 Being around other smokers
 Triggers and cravings
 Time pressure
 Stress in her life
Overcoming Roadblocks:
Negative Moods
 Engage in physical activity
 Express yourself (write, talk)
 Stress reduction/ relaxation
 Seek help with other psychological or social issues
 Think about pleasant, positive things
 Ask others for support
Overcoming Roadblocks:
Other Smokers
 Ask a friend or relative to quit with you
 Ask others not to smoke around you
 Assign nonsmoking areas
 Leave the room when others smoke
 Keep hands and mouth busy
Overcoming Roadblocks:
Triggers and Cravings
 Cravings will lessen within a few weeks
 Anticipate “triggers”: coffee breaks, social gatherings, being
on the phone, waking up
 Change routine—for example, brush your teeth immediately
after eating
 Distract yourself with pleasant activities: garden, listen to
music
Secondhand Smoke
The Debate Is Over
“The scientific evidence is now
indisputable: secondhand smoke is not a
mere annoyance. It is a serious health
hazard that can lead to disease and
premature death in children and
nonsmoking adults.”
What is secondhand smoke?
Secondhand Smoke (SHS) is the smoke that comes off
the end of a smoking cigarette and the smoke that
the smoker exhales
The Health Effects of Tobacco Use
Asthma
Otitis Media
Fire-related Injuries
SIDs
Bronchiolitis
Meningitis
Childhood
Infancy
In utero
Low Birth Weight
Stillbirth
Neurologic Problems
Influences
to Start
Smoking
Adolescence
Nicotine Addiction
Adulthood
Cancer
Cardiovascular Disease
COPD
Secondhand smoke is toxic:
4000 chemicals
> 50 Cancer-causing
chemicals
 Formaldehyde
 Benzene
 Polonium
 Vinyl chloride
Toxic metals:
 Chromium
 Arsenic
 Lead
 Cadmium
Poison Gases:
 Carbon
monoxide
 Hydrogen
cyanide
 Butane
 Ammonia
SHS and Children:
Short Term Health Effects
 Respiratory tract infections such as pneumonia &
bronchitis
 Decreased pulmonary function
 Triggers asthma attacks
 Ear Infection (Otitis Media)
 Tooth decay
 House fires
SHS and Children:
Long Term Health Effects
 Sudden Infant Death Syndrome (SIDS)
 Asthma
SHS exposure increases frequency of episodes and severity
of
symptoms
 200,000 annual cases of childhood asthma, attributed to
SHS
 Possible problems with cognitive functioning and behavioral
development
 More likely to become smokers
SHS and Adult Health Risks
Nonsmokers who are exposed to secondhand smoke at
home or at the workplace are at an increased risk of
developing;
 Lung cancer (20-30%)
 Coronary heart disease (25-30%)
 Acute respiratory problems
Case Study: Lisa
 17-year old
 Hospitalized 4 days &
 6 months pregnant, admitted
medicated to stop
contractions
to hospital for pre-term labor
 Smokes a pack & a half a day
and has smoked for 6 years
 Boyfriend smokes
 Contraction free & being
discharged
 Enjoys smoking & has no
interest in quitting
Case Study: Linda
27 years old
3 children ages 6,4, and 2 who
have asthma
Smokes 1 pack of cigarettes a
day
Has smoked for 14 years
Expresses little interest in
quitting
Case Study: John
 32-year old father
 Smokes a pack a day for past
14 years
 Had several prior quit
attempts
 Occasionally uses
 Has a son who has asthma
smokeless
tobacco instead of
cigarettes
 Concerned about stress with
 Wife encourages him to
work & home life and avoiding
weight gain
 Not sure about trying again
 John is sick with bronchitis
quit
Case Study: Grace
 55-year old women
 Has emphysema
 Smokes a pack a day for the past 30
years
 Has tried to quit several times in the
past
 Daughter and grandson lives with
her
Need more information?
The AAP Richmond Center
www.aap.org/richmondcenter
Audience-Specific Resources
State-Specific Resources
Cessation Information
Funding Opportunities
Reimbursement Information
Tobacco Control E-mail List
Pediatric Tobacco Control Guide