Transcript Smoking During Pregnancy

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Smoking Cessation
Survey

Can also be accessed at
https://www.surveymonkey.com/r/XR2BDSB
Smoke-Free Families National Program Office
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Nicotine Cessation Activities in
Pregnancy
Sharon Phelan MD
University of New Mexico
June 1, 2016
Objectives
1.
2.
3.
4.
5.
List medical and pregnancy related
complications
List factors for the initiation of smoking
Outline the Five A’s Approach to
smoking/nicotine cessation
Discuss the strategies to implement
cessation activities in practice
Outline role of pharmaceutical agents
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Smoke-Free Families National Program Office
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New Mexico
Data 2014
http://nccd.cdc.gov/STATESystem/rd
Page.aspx?rdReport=OSH_STATE.
Highlights
20% of all US
Deaths/year
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Thun MJ et. al. 50-year Trends in smoking related mortality in the US.
NEJM 2013;368:351-64
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What is being done
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Clean Air Acts to prevent smoking in
public places
Laws to prohibit underage to purchase
Taxation on each pack of cigarettes
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Smoke-Free Families National Program Office
Increasing Cost
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U.S. Demographics of the
Female Smoker
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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.
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Risk Factors For Smoking
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Low Education (< HS 20%)
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Less than 20 yo (17.3%)
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Unintended Pregnancy (18.9%)
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Income less than 25K (17.5%)
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Medicaid Recipient (16.5%)
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Partner Who Smokes
Prenatal/Neonatal Outcomes
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20-30% low birth weight infants
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Fetal growth retardation
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Miscarriage & pre-term deliveries -16%
(Increased by 25%)
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Stillbirth (increased by 60%)
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Ectopic pregnancies
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Placenta previa and abruption
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Lower APGAR
Most
common preventable cause of poor birth outcomes
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Smoking during Pregnancy
Reasons for Reduced Fetal Growth
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Lower maternal weight gain
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Vasoconstriction and decreased
uterine blood flow
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Carbon monoxide toxicity
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Increased cyanide production
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Smoking during Pregnancy
Passive Exposure
Maternal exposure to passive
smoking in early pregnancy more
than doubles the risk of delivering
a small-for-gestational-age infant.
Dejin-Karlsson
AJPH, 1998
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Prevalence
of smoking
during
pregnancy
by state
Smoke-Free Families National Program Office
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Percentage of
women who
report smoking
in NM
In 3 months
prior to
conception:
19%
In last 3
months of Pg:
8.6%
Smoke-Free Families National Program Office
Smoking During
Pregnancy
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42
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High School
< High School
> High School
30
28
% Current Smokers
40
25
23
20
20
17
15
10
10
9
6
4
5
6 5
4 3
2
1
0
White
Black
Hispanic
Race/Ethnicity
Amer.
Indian
Asian
22
13%
Smoke-Free Families National Program Office
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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
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% Abstaining
Postpartum Smoking Cessation
100
90
80
70
60
50
40
30
20
10
0
0
1
2
3
4
5
6
Months from Delivery
Mullen, 1990
Smoke-Free Families National Program Office
Why Do Women Smoke
?
To Keep a
slender figure
no one can
deny…
Reach for a
LUCKY
instead of a
sweet
Smoking is
Glamorous,
Sophicated,
Note-Marlboro
Virginia Slims
remembers the
first Women’s
Board Meeting
Professional
In Control
Fun-Loving
& Sexy
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SNUS tobacco
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Smokeless form of tobacco
Spit-less moist snuff
“Socially acceptable” since no smoke
Camel and Marlboro have marketed
Same risk of stillbirth as cigarettes
Same risk of preterm birth
Epidemiology 8-27-10
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Smoke-Free Families National Program Office
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E-Cigarettes
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Side
Effects
of
Nicotine
Smoke-Free Families National Program Office
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Addiction
cycle for
Nicotine
Motivators for Women to Stop
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Health issues for children at home
Peers/friends/family stop smoking
Personal appearance – wrinkles, stained
teeth etc
The health of her fetus – high rate of
cessation in pregnancy but a 50-60%
relapse after birth
The Process of Behavior
Change and Pregnancy
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Pregnant women often are more open to change (The
fetus can be a wonderful motivator)
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May have more support to quit while pregnant
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May not be socially acceptable to smoke in public if
pregnant
Smoking Cessation During Pregnancy ACOG CO #316,
2005
Spontaneous Quitters and Continuing
Smokers: Important differences
Spontaneous quitters
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Having first child
Planned pregnancy
Early prenatal care
Nausea in 1st trimester
Intending to breastfeed
Previous miscarriage
Less nicotine
dependent
More previous quit
attempts
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Higher SES
More education
Partnered/Married
Strong belief in the
harm to the baby
Privately insured
Spontaneous Quitters and Continuing
Smokers: Important differences
Continuing Smokers
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Smoked with previous
pregnancies
More saturated smoking
networks
Smoking partner
More life stressors
Weaker belief in the harm
to the baby from maternal
smoking
Lower SES, less
education
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Smoking Cessation During Pregnancy
Current Practice
ACOG Survey
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Discuss adverse effects
94%
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Advise to stop smoking
93%
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Advise to “cut down”
78%
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Assist in planning
56%
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Provide self-help materials
35%
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Refer
20%
Why Won’t the Providers Get
on Board?
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Time, time, time
Not convince that make a difference
Too few providers – need to
concentrate on ob care not
behavioral issues
Billable?
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The Five A’s from NCI
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Ask
Advise/Educate
– Clear message to quit and the benefits
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Assess
– Past and current level of smoking
– Current stage in quitting process
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Assist - through the stages of change
Arrange Follow-up - what ever stage
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.
Mullen et al., 1991
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Recommended Multiple-Choice Question
Which of the following statements best describes your
cigarette smoking? Would you say:
1. I smoke/vape regularly now -- about the same amount
as before finding out I was pregnant.
2. I smoke/vape regularly now, but I’ve cut down since I
found out I was pregnant.
3. I smoke/vape every once in a while.
4. I have quit smoking/vaping since finding out I was
pregnant.
5. I wasn’t smoking/vaping around the time I found out I
was pregnant, and I don’t currently smoke/vape.
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ADVISE:
Provide clear, strong advice to
quit with personalized messages
about the impact of smoking and
quitting on the woman and her
family
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ASSESS:
 Prior and current levels of smoking
 Assess the willingness of the patient
to attempt to quit within 30 days
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ASSIST:
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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
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ASSIST:
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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
Alternate Model: AAR
ASK
ADVISE
REFER
about tobacco USE
tobacco users to QUIT
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ARRANGE:
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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
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Patient Not Interested? – 5 R’s
Have patient help identify her views Relevance to the patient
 Risks of Smoking
 Rewards of cessation
 Roadblocks and barriers
 Repeat each visit
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Implementing Cessation Activities
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Develop administrative commitment
Involve office staff early in developing
implementation planning
Assign staff to monitor implementation
Train clinical and/or support staff
Adapt procedures to specific setting
Evaluate and give feedback to staff
Adapted from Make Yours a Fresh Start Family
Smoke-Free Families National Program Office
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Implementing Cessation Programs
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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
Adapted from Make Yours a Fresh Start Family
Smoke-Free Families National Program Office
Pharmacological Approach
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Medications
– Nicotine replacement
– Bupriopion HCl (Wellbutrin® )
– Varenicline (Chantix ®)
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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.
Pharmacologic Interventions
during Pregnancy
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The efficacy and safety of these pharmacological
approaches during pregnancy is unknown.
(USPSTF)
Most are FDA “C” except for nicotine patch and
inhaler which are a “D”
During breastfeeding:
– Probably safe: nicotine replacement modalities
– Unknown: Varenicline
– Possibly unsafe: Buproprion
Swamy – AJOG 2009:354.
Osadchy – Obstet gynaecol Can 2009;31:744-47
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Risks for Postpartum Relapse
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African American women
Weight gain > 35 pounds during
pregnancy
Higher smoking levels before quitting
High stress during pregnancy
Partner/family/co-workers who smoke
Postpartum depression
Am J Prev Med Sept 2000 Carmichael
Postpartum Follow-up/Support
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During pregnancy Ob provider can see
her every 1-4 weeks to provide support
Postpartum only can see once 4-6
weeks
Pediatricians see mom’s with child
frequently – do we need to recruit them
to monitor and help mom?
Family Medicine can do both !!!!
State Quitlines
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Available in all 50 states & DC
Can be accessed through 1-800-QUIT-NOW
Geared to non-pregnant clients
Provide counseling and support to quit
 Provide information about medications
 Up to 3 months free NRT (non-Pg)
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Convenient and free
Capacity and services vary across states
Key Resources
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www.cdc.gov/tobacco/
www.surgeongeneral.gov/tobacco
For providers
 www.ahrq.gov/clinic/tobacco/tobaqrg.htm
 www.aafp.org/
 Smoking Cessation for Pregnancy and Beyond
https://www.smokingcessationandpregnancy.org/
For patients
 www.smokefree.gov
 1-800-QUIT NOW
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https://www.smokingcessationandpregnancy.org/
©
Successful Interventions
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Include the smoking habits of partners, others
living in the home, and close friends
Support the women with positive
encouragement rather than negative nagging
Encourage a woman’s social networks to
support her
Take place throughout pregnancy and through
early childhood care
Summary
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More young women are initiating
smoking/vaping
Smoking/Nicotine is one of the largest
modifiable risk for poor pregnancy outcome
Nicotine Cessation programs including 5
A’s program at primary doctor’s office or 3
A’s and then R
Follow up for relapse at each visit.
Comments from the Audience