1. Smoking Cessation Survey l Can also be accessed at Smoke-Free Families National Program Office 1 https://www.surveymonkey.com/r/XR2BDSB

2. 2 Nicotine Cessation Activities in Pregnancy Sharon Phelan MD University of New Mexico June 1, 2016

3. Objectives 1. 1. List medical and pregnancy related complications 2. 2. List factors for the initiation of smoking 3. 3. Outline the Five A’s Approach to smoking/nicotine cessation 4. 4. Discuss the strategies to implement cessation activities in practice 5. 5. Outline role of pharmaceutical agents

4. Smoke-Free Families National Program Office 4

5. http://nccd.cdc.gov/STATESystem/rd Page.aspx?rdReport=OSH_STATE. Highlights 5 New Mexico Data 2014

6. 20% of all US Deaths/year

9. 9 Thun MJ et. al. 50-year Trends in smoking related mortality in the US. NEJM 2013;368:351-64

10. What is being done l Clean Air Acts to prevent smoking in public places l Laws to prohibit underage to purchase l Taxation on each pack of cigarettes 10

11. Smoke-Free Families National Program Office 11

12. Increasing Cost

13. 13

14. 14 U.S. Demographics of the Female Smoker l 22 million adult women smoke l 1.5 million female adolescents smoke l The earlier woman starts, the more likely she will be a heavy smoker as an adult l over 500,000 female start smoking each year with 85-90% of those being teens l Use typically begins by age 16; and almost certainly by 21.

15. 15 Risk Factors For Smoking l Low Education (< HS 20%) l Less than 20 yo (17.3%) l Unintended Pregnancy (18.9%) l Income less than 25K (17.5%) l Medicaid Recipient (16.5%) l Partner Who Smokes

16. Prenatal/Neonatal Outcomes  20-30% low birth weight infants  Fetal growth retardation  Miscarriage & pre-term deliveries -16% (Increased by 25%)  Stillbirth (increased by 60%)  Ectopic pregnancies  Placenta previa and abruption  Lower APGAR  Most common preventable cause of poor birth outcomes

17. 17 Smoking during Pregnancy Reasons for Reduced Fetal Growth l Lower maternal weight gain l Vasoconstriction and decreased uterine blood flow l Carbon monoxide toxicity l Increased cyanide production

18. 18 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

19. Prevalence of smoking during pregnancy by state Smoke-Free Families National Program Office 19

20. Smoke-Free Families National Program Office 20 Percentage of women who report smoking in NM In 3 months prior to conception: 19% In last 3 months of Pg: 8.6%

21. Smoking During Pregnancy High School > High School < High School

22. Smoke-Free Families National Program Office 22 13%

23. 23 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

24. Smoke-Free Families National Program Office 24 Postpartum Smoking Cessation Mullen, 1990

25. Why Do Women Smoke ?

26. To Keep a slender figure no one can deny… Reach for a LUCKY instead of a sweet

27. Smoking is Glamorous, Sophicated, Note-Marlboro

28. Virginia Slims remembers the first Women’s Board Meeting

29. Professional In Control

30. Fun-Loving & Sexy

31. SNUS tobacco l Smokeless form of tobacco l Spit-less moist snuff l “Socially acceptable” since no smoke l Camel and Marlboro have marketed l Same risk of stillbirth as cigarettes l Same risk of preterm birth Epidemiology 8-27-10 31

32. Smoke-Free Families National Program Office 32

33. E-Cigarettes 33

34. 34

35. Side Effects of Nicotine Smoke-Free Families National Program Office 35

36. 36 Addiction cycle for Nicotine

37. Motivators for Women to Stop l l Health issues for children at home l l Peers/friends/family stop smoking l l Personal appearance – wrinkles, stained teeth etc l l The health of her fetus – high rate of cessation in pregnancy but a 50-60% relapse after birth

38. The Process of Behavior Change and Pregnancy  Pregnant women often are more open to change (The fetus can be a wonderful motivator)  May have more support to quit while pregnant  May not be socially acceptable to smoke in public if pregnant Smoking Cessation During Pregnancy ACOG CO #316, 2005

39. Spontaneous Quitters and Continuing Smokers: Important differences Spontaneous quitters l Having first child l Planned pregnancy l Early prenatal care l Nausea in 1 st trimester l Intending to breastfeed l Previous miscarriage l Less nicotine dependent l More previous quit attempts l Higher SES l More education l Partnered/Married l Strong belief in the harm to the baby l Privately insured

40. Spontaneous Quitters and Continuing Smokers: Important differences l Smoked with previous pregnancies l More saturated smoking networks l Smoking partner l More life stressors l Weaker belief in the harm to the baby from maternal smoking l Lower SES, less education Continuing Smokers

41. 41 Smoking Cessation During Pregnancy Current Practice ACOG Survey l Discuss adverse effects94% l Advise to stop smoking93% l Advise to “cut down” 78% l Assist in planning 56% l Provide self-help materials 35% l Refer20%

42. Why Won’t the Providers Get on Board? l l Time, time, time l l Not convince that make a difference l l Too few providers – need to concentrate on ob care not behavioral issues l l Billable?

43. 43 The Five A’s from NCI l Ask l Advise/Educate –Clear message to quit and the benefits l Assess –Past and current level of smoking –Current stage in quitting process l Assist - through the stages of change l Arrange Follow-up - what ever stage

44. 44 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

45. 45 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.

46. 46 ADVISE : Provide clear, strong advice to quit with personalized messages about the impact of smoking and quitting on the woman and her family

47. 47 ASSESS :  Prior and current levels of smoking  Assess the willingness of the patient to attempt to quit within 30 days

48. 48ASSIST: l Develop a quit plan including a quit date l Review preparations for quitting l Offer pharmaceutical therapy l Provide educational materials l Provide/refer to skills training and/or social support programs

49. 49ASSIST: l Develop a quit plan including a quit date l Review preparations for quitting l Offer pharmaceutical therapy l Provide educational materials l Provide/refer to skills training and/or social support programs

50. Alternate Model: AAR ASK about tobacco USE tobacco users to QUIT ADVISE REFER

51. 51ARRANGE: l Periodic follow up visits : first within 2 weeks, second within the month and subsequent as needed l If abstaining: Praise and see how can help l If relapsed: –Ask for recommitment –Remind patient we learn from our mistakes –Id the problems and think about new approach

52. Patient Not Interested? – 5 R’s Have patient help identify her views- l Relevance to the patient l Risks of Smoking l Rewards of cessation l Roadblocks and barriers l Repeat each visit 52

53. Smoke-Free Families National Program Office 53 Implementing Cessation Activities l Develop administrative commitment l Involve office staff early in developing implementation planning l Assign staff to monitor implementation l Train clinical and/or support staff l Adapt procedures to specific setting l Evaluate and give feedback to staff Adapted from Make Yours a Fresh Start Family

54. Smoke-Free Families National Program Office 54 Implementing Cessation Programs l Develop administrative commitment l Involve staff early in implementation planning l Assign staff to monitor implementation l Train clinical & support staff l Adapt procedures to specific setting l Evaluate and give feedback to staff Adapted from Make Yours a Fresh Start Family

55. Pharmacological Approach l l Medications – –Nicotine replacement – –Bupriopion HCl (Wellbutrin® ) – –Varenicline (Chantix ®) l 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.

56. Swamy – AJOG 2009:354. Osadchy – Obstet gynaecol Can 2009;31:744-47 56 Pharmacologic Interventions during Pregnancy l The efficacy and safety of these pharmacological approaches during pregnancy is unknown. (USPSTF) l Most are FDA “C” except for nicotine patch and inhaler which are a “D” l During breastfeeding: –Probably safe: nicotine replacement modalities –Unknown: –Unknown: Varenicline –Possibly unsafe: Buproprion

57. Risks for Postpartum Relapse l African American women l Weight gain > 35 pounds during pregnancy l Higher smoking levels before quitting l High stress during pregnancy l Partner/family/co-workers who smoke l Postpartum depression Am J Prev Med Sept 2000 Carmichael 57

58. Postpartum Follow-up/Support l l During pregnancy Ob provider can see her every 1-4 weeks to provide support l l Postpartum only can see once 4-6 weeks l l Pediatricians see mom’s with child frequently – do we need to recruit them to monitor and help mom? l l Family Medicine can do both !!!!

59. 59 State Quitlines  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)  Convenient and free  Capacity and services vary across states

60. Key Resources  www.cdc.gov/tobacco/ www.cdc.gov/tobacco/  www.surgeongeneral.gov/tobacco www.surgeongeneral.gov/tobacco For providers  www.ahrq.gov/clinic/tobacco/tobaqrg.htm www.ahrq.gov/clinic/tobacco/tobaqrg.htm  www.aafp.org/ www.aafp.org/  Smoking Cessation for Pregnancy and Beyond https://www.smokingcessationandpregnancy.org/ https://www.smokingcessationandpregnancy.org/ For patients  www.smokefree.gov www.smokefree.gov  1-800-QUIT NOW

61. 61 https://www.smokingcessationandpregnancy.org/

62. © Successful Interventions l Include the smoking habits of partners, others living in the home, and close friends l Support the women with positive encouragement rather than negative nagging l Encourage a woman’s social networks to support her l Take place throughout pregnancy and through early childhood care

63. Summary l l More young women are initiating smoking/vaping l l Smoking/Nicotine is one of the largest modifiable risk for poor pregnancy outcome l l Nicotine Cessation programs including 5 A’s program at primary doctor’s office or 3 A’s and then R l l Follow up for relapse at each visit.

64. Comments from the Audience