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Alice Ordean MD, CCFP, MHSc Medical Director, T-CUP, SJHC November 30, 2011.

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Presentation on theme: "Alice Ordean MD, CCFP, MHSc Medical Director, T-CUP, SJHC November 30, 2011."— Presentation transcript:

1 Alice Ordean MD, CCFP, MHSc Medical Director, T-CUP, SJHC November 30, 2011

2 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 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 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 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 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:

7 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 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 Pregnancy Complications Neonatal Effects Long-Term Effects Subfertility (female and male) Ectopic pregnancy (outside the uterus) Spontaneous abortion (miscarriage) Preterm labour Premature rupture of membranes Placental problems (previa & abruption) Growth restriction Low birth weight (on average ~200 grams smaller) Increased perinatal mortality Increased admission to the neonatal intensive care unit (NICU) Sudden infant death syndrome (SIDS) Decreased volume of breast milk and duration of breastfeeding Childhood respiratory illnesses (asthma, pneumonia, bronchitis) Other childhood medical problems (ear infections) Learning problems (reading, mathematics, general ability) Behavioral problems Attention deficit hyperactivity disorder (ADHD) [1] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005

10 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 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 1. Woman-centred care: care focused on womans needs in context of social, economic life circumstances eg. Focus on womans health before and during pregnancy 2. Harm reduction: focus on reducing harm to woman & fetus from effects of smoking eg. Reduced smoking, nicotine replacement tx 3. Reducing stigma to help engage pregnant smokers: deal with pressures to quit smoking

13 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 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 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 16 Precontemplation Contemplation Preparation Action Maintenance Progress Relapse

17 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 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 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 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 Stage of changeIntervention Pre-contemplativeInitiate discussion about impact of smoking on patients life, encourage smoke free house/car & provide educational materials ContemplativeIncrease motivation to quit: offer help, complete decisional balance – pros & cons of smoking and quitting PreparationHelp find right treatment: plan for quitting eg. past quit hx, barriers & smoking triggers, set quit date ActionSupport & sustain cessation efforts: coping strategies, medications, follow-up visits MaintenanceRelapse prevention counselling

22 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 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 Be aware of whats 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 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 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 Second-line treatment options during pregnancy may include: Nicotine replacement therapies Bupropion (Zyban) Varenicline (Champix)

28 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 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 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 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 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 No evidence regarding safety of varenicline during pregnancy; therefore, its use during pregnancy is not recommended.

34 ASKSmoker ADVISE to quit or reduce smoking ARRANGE follow-up ASSIST by providing brief interventions or making referral Non-smoker ASK about second- hand smoke exposure

35 PREGNETS [specialized toolkit to address smoking cessation among pregnant & postpartum women] CAN-ADAPTT [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 CAMH Nicotine Dependence Clinic Ontario Smokers Helpline Motherisk or

37 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 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 or

40 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 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 One to one individual counselling appointments Quit smoking groups Telephone counselling Provision of self-help resources Funded by Health Canada to March 2012

43 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 Womens Health In Ontario to March 2013

44 Free, confidential phone, online and text messaging services at and English, French and interpreter service Accept Fax Referrals from health care providers through Quit Connection program ( Specialized protocols in place to serve pregnant and post- partum women Ann Burke ext

45 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 womans 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

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