1. Better Practices for Addressing Prenatal and Postpartum Tobacco Use Supporting Women to Stop Smoking: Click to start

2. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011 Acknowledgements Module content prepared by: Phyllis Price (Public Health Services) South Shore Health Raymond Gaudet (Public Health Services) South West Health Valerie Blair (Public Health Services) Annapolis Valley Health Melanie Welch (Public Health Services) Annapolis Valley Health Module designed by: Melanie Belliveau (Library Services) Annapolis Valley Health Online Adaptation by: Nancy Green (Public Health Services) South Shore Health Module reviewed by: Gwenyth Dwyn (Addiction Services) Annapolis Valley Health Sheila Levy (Public Health Services) Annapolis Valley Health Kara Monroe (Addiction Services) Annapolis Valley Health Feedback survey designed by: Sheila Levy (Public Health Services) Annapolis Valley Health Jackie MacDonald (Library Services) South Shore Health Special thanks to: Dr. Lorraine Greaves, Dr. Renee Cormier, Karen Devries, Dr. Joan Bottorff, Dr. Joy Johnson, Dr. Susan Kirkland and Dr. David Aboussafy, authors of Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women (Health Canada, 2003), the seminal work on which much of this module is based. Dr. P. Selby and the Pregnets Project at the Centre for Addictions and Mental Health (Toronto) for permission to adapt their training slides (developed with funding from Health Canada Tobacco Control Programme). Special thanks to all who responded with feedback to the pilot; it helped to make this module a more useful learning tool.

3. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011 Purpose This learning module is an orientation for health and allied professionals on issues around pregnancy and tobacco and how to best address tobacco use among pregnant and postpartum women and girls. This module will: Provide background on tobacco use in Nova Scotia Highlight better practices in supporting women and girls to stop smoking Suggest resources for further learning To navigate the tutorial: Use these buttons to move through the tutorial Indicates further information available by clicking on the button Terms in RED are defined at the end of the document in the glossary

4. Test Your Awareness Click on the answer you believe to be correct for each of the questions. When finished, click on “Return to Tutorial” (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

5. What percentage of women in Nova Scotia smoke during pregnancy? 10 16 21 26 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

6. In general, how many women who smoke will try to stop smoking during pregnancy? 35 50 80 90 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

7. In general, how many women who stop smoking during pregnancy will start within one year? 20-30% 55-75% 65-85% 70-90% (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

8. Tobacco Control in Nova Scotia Try Quiz Again (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

9. Advances Nova Scotia has seen many recent advances in tobacco control such as lower rates of smoking in the province. 200030%* (smoking rate highest in the country) 201021%* (smoking rate 8 th lowest in the country) Much of this change is due to the implementation of a provincial comprehensive tobacco strategy. Learn more at the provincial tobacco strategy here.here (*Smoking population, aged 15+, NS; Canadian Tobacco Use Monitoring Survey, Health Canada) (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

10. Legislation Nova Scotia has some of the best tobacco-free legislation in the world: Smoking is prohibited in all workplaces (including restaurants, bars, and outdoor service industry patios); within 4 meters of an intake for a building ventilation system, an open window or an entrance to a place of employment; or in a motor vehicle when any person under the age of 19 is present in the vehicle. In 2007, it was the first Canadian province to pass a law prohibiting smoking in cars where children under 19 are present More communities are banning smoking in outdoor recreational spaces, such as playgrounds, parks, sports fields and other outdoor places where people gather. To find out why smoke free outdoor spaces is a good idea, visit here.visit here (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

11. Reality Check Despite these advances, many women who are pregnant smoke. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

12. Who is Most Likely to Smoke? Women with low income Women with no partner Women with heavier smoking addiction (20+ cigarettes/day) Younger women (Rates for pregnant women under 20 years of age are especially high. In 2009, 56% of pregnant women aged 17-18 in Nova Scotia smoked at some point during their pregnancy) 1 Women who have not planned to get pregnant Women who do not feel pregnant Women experiencing physical discomfort (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

13. Reasons Pregnant Women Continue to Smoke Nicotine addiction Other priorities No other coping skills ‘Fitting in” (varies according to education level and socio-economic status) Controlling weight – fear of weight gain Fear of being without cigarettes, loss (‘it’s my only friend’) Shame, guilt (prevent her from seeking assistance) 4 Support person/partner continues to smoke The mistaken belief that a lower birth weight (smaller baby) will mean an easier labour (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

14. Reduce Stigma Acknowledge the negative social responses to and judgment of pregnant women who smoke. Assist in dealing with stigma, punishment and blame. Recognize that smoking is a secondary issue for many women – issues such as poverty, violence or other health issues may be more important in their lives. Examine your own attitudes and biases about women continuing to smoke while pregnant. Challenging ones’ own thinking can help to ensure that women are seen as unique individuals, not as labels or stereotypes (eg. Just mothers of children or unborn children). “When visibly pregnant, a woman may feel harassed by strangers when smoking in public, which may heighten her feelings of shame. It’s important for health practitioners to acknowledge that quitting is a difficult process and that the woman may have public experiences about her smoking.” ~ Greaves et al. (2003) 2 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

15. Why Focus on Cessation During Pregnancy? Because the health effects of smoking and second-hand smoke (Environmental Tobacco Smoke) are preventable BUT, it’s important the focus be on the woman’s life circumstances, not focused on the fetus or the pregnancy (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

16. Better Practices: Providing Woman-Centered Care (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

17. Better Practices Approach 2 7 Elements 1.Provide woman-centred care 2.Tailor programs to the individual 3.Reduce stigma 4.Prevent relapse (starting to smoke again); provide follow-up 5.Use a harm reduction approach 6.Explore support from partner and family 7.Integrate social issues (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

18. WOMAN- CENTERED CARE IS 6 : Empowering Involves women as informed participants in their own health care with the right to control their own bodies Respectful of Diversity Recognizes the impact of differences and of social and economic location Safe Establishes emotionally, spiritually, culturally and physically safe environments Holistic Avoids unnecessary medicalization and uses a biopsychosocial model Comprehensive Involves care, health promotion, education, prevention, treatment and rehabilitation Individualized Considers health concerns unique to each woman and her personal experience in all her roles Focused on Social Justice Solicits participation of women in planning, evaluation, policy and research Advocates for women’s issues Participatory Involves women and recognizes women have authority on their own lives (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

19. Tailor to the Individual When addressing tobacco use, take into account: Life issues of the woman Family of origin and family dynamics Mental health of the woman Social environment Other determinants of health “Today, cigarette smoking in high-income countries is a marker of social disadvantage, increasingly confined to areas and communities scarred by long-term unemployment, poor housing, and limited public services” ~Hilary Graham 7 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

20. Prevent Relapse; Provide Follow-Up 10 Identify women who stop smoking during pregnancy and support them pre- and post-partum Stay woman-focused Use a non-judgmental approach-keep connection Re-motivate to deal with new pressures after baby is born Distinguish between slips and relapse Start to discuss, early in the process of stopping smoking, how to identify high risk situations and deal with triggers Expect temptations and urges, slips Providing breastfeeding support may help encourage some mothers to remain smoke free or to delay a return to smoking To stop smoking is a long and difficult process. It is a journey rather than a destination (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

21. Slips vs. Relapse 11 Slip A slip is when a woman has a cigarette or two after having stopped smoking. It does not mean she has failed or can’t stop smoking. You can say to the woman: This is just a slip; it is minor. Go back to stop smoking as soon as you can. Look at what led to the slip and figure out how to handle it differently. Relapse A relapse is when the woman starts smoking again on a regular basis. It does not mean that she has failed or can’t stop smoking. You can say to the woman: To stop smoking is a process. Most people will make 3-10 serious attempts before they stop smoking for good. Don’t feel discouraged Look at what led to the relapse and figure out how to handle it differently. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

22. What Can Influence Relapse… … During Pregnancy Not stopping completely Having less confidence in being able to stay smoke free Younger age Heavier smoking before pregnancy Experiencing less nausea Partner smoking … Postpartum Bottle feeding Perceiving less risk of smoking on the baby Stopped for the baby rather than for self Using smoking as a reward Partner smoking Fear of weight gain (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

23. Engage Partner and Family The presence of fathers, partners and others who smoke in the pregnant woman’s social network affect: the extent the woman and the fetus are exposed to second hand smoke and the likelihood that she will not have support to stop smoking 2 Address partner smoking separately from the woman’s attempt to stop smoking. To explore addressing partner smoking, this is a good resource.this Smoking can be a source of conflict among families. Stopping smoking or not stopping smoking can increase the conflict. Women living with partners who smoke are more likely to continue smoking during their pregnancy or relapse of they had previously stopped smoking. 12 “One of the most significant reasons for women to relapse is lack of support from their partner, friends and family.” ~ CAMH (2007) 8 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

24. Integrate Social Issues and Supports Acknowledge the negative social responses such as judgment, punishment and blame directed towards pregnant women who smoke. Validate her entitlement to social support—because of stigma and the resulting shame, a woman may not feel that she deserves help. 8 Encourage women to find appropriate support (e.g., confiding in a trusted friend, seeking a referral for additional services). Refer to community based organizations that can provide social support. Recognize that smoking is a secondary issue for many women – issues such as poverty, violence, single-parenting, unemployment, etc. may be more primary in their lives. 9 Work to change policy and programs to be more supportive of women. “When working with pregnant women who smoke, it’s important to examine our own attitudes and biases about women continuing to smoke while pregnant.” ~ Health Canada (2005) 5 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

25. Use a Harm Reduction Approach For women who are heavily addicted and have not had success stopping smoking, or women who aren’t interested in quitting, a harm reduction approach is helpful. Encourage: Reducing the number of cigarettes smoked Stopping for brief periods of time Engaging in other healthy lifestyle If counselling is not successful, suggest that the woman talk to her family doctor about Nicotine Replacement Therapy (NRT), such as gum, or inhaler. The risk of cigarette smoking during pregnancy is greater than the risk of exposure to pure nicotine as used in NRT. Using NRT limits exposure to carbon monoxide, tar, hydrogen cyanide and other chemicals. It is recommended that the start date for NRT be after the first trimester, and it only be used during the day. There is no known safe level for smoking or second hand smoke. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

26. Applying Better Practices to Support Women (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

27. Challenges (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

28. Challenges for Service Providers 13 No time to provide interventions Lack of knowledge about tobacco use Competing priorities Lack of skills or successes around helping others stop smoking Mistaken assumptions… (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

29. Service Providers: Mistaken Assumptions Pregnancy is a good thing Keep in mind that the pregnancy may not have been planned or may be causing a lot of stress in the woman’s life. She may not have considered stopping smoking at all prior to pregnancy, and may be resistant to the idea of not smoking. 16 Expectant mothers know tobacco is harmful Some women are not necessarily well-informed about the health effects of smoking on the fetus. Ask the client what she knows about the harmful health effects of tobacco and then what her concerns are, if any. Health of the fetus should be a strong enough motivation to stop smoking The fetus-centered approach may be unsuccessful and short lived. It encourages external motivations, as well as feelings or guilt and fear. It is important to focus on the mother as we well the fetus. If a woman (unprompted) brings up the fetus as her motivation, be sure to acknowledge and support this, but also work to move her to consider other internal and longer term motivators. It is important to give the message that she will have the most success to stop smoking if she does it for herself. Any positive impact of her stopping smoking for others (fetus, baby or other non-smokers in the house) can be seen as an important ‘bonus’ rather than a primary reason to stop smoking. 16 The pregnant woman’s partner will want her to stop smoking also Remember that the woman may or may not have a partner present in her life, and if present, the partner may not be supportive about the pregnancy or about the woman’s attempt to stop smoking. Also, a partner may be male or female. 17 The woman has told her doctor and other health care providers that she smokes Pregnant women who smoke are often stigmatized and are thus uncomfortable telling others that they smoke. Her health care providers may or may not be aware that she is smoking or that she may have spontaneously or temporarily stopped smoking. 16 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

30. Challenges for Women 13 Shame Closet smoking behaviours Mistaken assumptions… (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

31. Pregnant Women’s Mistaken Assumptions Smaller babies are easier to deliver It is not always easier to deliver a low-birth weight baby. And a baby that weighs too little is often sick with lots of health problems. Smaller babies are more likely to need special care and stay longer in the hospital. Some may die either at birth or within the first year. 17 It’s too late to do any good It’s never too late to do any good. If you stop smoking at any time it has immediate health benefits for both the mother and the baby, regardless of previous smoking or future relapse. 9 My other babies were okay They may be the lucky ones! If a woman smokes during pregnancy she takes a chance with her baby’s health. There is an increased risk of losing the baby during pregnancy. The baby could also be born too early, before the lungs are ready, so he or she may have trouble breathing. Also, the effects of the child’s behaviour and attention span may not be detected till the child is much older My doctor said to stop smoking cold turkey would be dangerous to my baby It is safe to stop smoking cold turkey. Pregnant smokers can cut down on the number of cigarettes, but the best option is to stop smoking completely. 9 It will be easier to stop smoking after the baby is born Parenting a newborn baby can be stressful. Women often find it easier to stop smoking before the baby is born, rather than when they are struggling with the added pressures of parenting a newborn (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

32. Myths & Facts Myth: To prevent any harmful effects that could put the fetus or child at risk, a woman must completely stop smoking during pregnancy. 8 Fact: Smoking is extremely addictive and some women find it tremendously difficult to stop smoking. However, by reducing the number of cigarettes smoked each day, adverse effects can be minimized. If they can’t stop, women should be encouraged and supported to cut down on the quantity smoked. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

33. Myths & Facts Myth: To stop smoking cold turkey is dangerous to the fetus. 9 Fact: It is safe to stop smoking ‘cold turkey’. Pregnant women who smoke can cut down on the number of cigarettes but the best option is to stop smoking completely. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

34. Myths & Facts Myth: Helping pregnant women stop smoking is no different from helping any person who smokes. 9 Fact: Pregnant women who smoke have unique cessation issues compared to the general population. High postpartum relapse rates demonstrate that it is inappropriate to treat pregnant women in the same way as the general population that smokes. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

35. Myths & Facts Myth: A woman who smokes in her third trimester will lower the birth weight of her baby and will therefore have an easier labour. 8 Fact: While smoking in the third trimester may lower a baby’s birth weight to some extent, the amount is probably not enough to significantly ease labour. Further, low birth weight can result in potentially significant complications for the baby. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

36. Fact: The best advice for a woman of any age who smokes is to stop smoking. However, women who have recently had a baby but have been unable to stop smoking can still breastfeed. Studies have shown that breastfed babies are healthier than formula-fed babies, even when they get the chemicals from smoking or second- hand smoke in the breast milk. Myths & Facts Myth: A woman who smokes should not breastfeed her baby. 14 (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

37. Myths & Facts Myth: If I switch to light cigarettes, I won’t do as much harm to myself and my baby. 9 Fact: Light and mild cigarettes are not less dangerous than regular cigarettes. Due to the perception of lower levels of nicotine most people who smoke will compensate by inhaling more deeply, covering the air holes on the filter, or smoking more of each cigarette. This causes them to inhale more tar and other chemicals. Note: As of August 2007, a settlement between the Canadian Government and Canadian Tobacco Manufacturers phased out the terms ‘light’ and ‘mild’ on cigarette packaging. However, tobacco manufacturers have and continue to redesign cigarette packaging; the colours, logos and other packaging characteristics convey to the consumer the same message as ‘light’ and ‘mild’ cigarettes so the consumer thinks the product delivers lower levels of toxic components and is less harmful. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

38. How to Help (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

39. Ask It is important to bring up the topic smoking. However, how you ask is important… “Have you used any form of tobacco in the last 6 months?” “If yes, in the last 7 days?” (Reference: Ottawa Model for Smoking Cessation) (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

40. Advise Provide clear personalized advice to stop smoking, such as: “Stopping smoking is the best thing you can do for your health.” (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

41. Assess Motivation to Change Motivation is on a continuum Internal (stop smoking for self) External (stop smoking for the fetus or another person) While external reasons shouldn’t be ignored, internal reasons are more likely to lead to being smoke-free longer-term. ExternalInternal Less likely to stay smoke-free More likely to stay smoke-free Explore the woman’s reasons to stop smoking or to cut back. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

42. Motivational Interviewing Motivational Interviewing (MI) is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. 11 General principles in effective counselling: Listen well and express empathy Summarize to reflect back what the client is telling you Roll with resistance and ask open-ended questions Help bring the client to an awareness of the difference between their current behaviour and their goals Reframe statements for client to examine their perceptions in a new light. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

43. Assist Refer to community resources, such as a nicotine counsellor at Addiction Services Refer to a healthcare provider (for stop smoking medications) Suggest and encourage the use of problem solving methods to stop smoking Provide pregnancy specific self-help stop smoking material Provide contact information for: –Smoker’s Helpline (1-877-513-5333) –Smoker’s Online Support (www.smokershelpline.ca)www.smokershelpline.ca Arrange follow-up on future visits to monitor progress and provide support –Encourage her –Express willingness to help –Ask about concerns or difficulties –Invite her to talk about success (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

44. Important Things to Consider Listen more than talk Support and Encourage Believe in her ability to stop smoking Help women express their feelings Address postpartum relapse during and after pregnancy Include smoking partners in interventions Integrate social issues and supports Remember that not all women are the same Refer to the 5As in the Glossary Reminder! (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

45. Remember, Success Is… Maintaining Contact Understanding that to stop smoking is a process, not an event Any change that moves her closer to not smoking (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

46. Almost Done! Final Quiz (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

47. What Percentage of Pregnant Women in Nova Scotia Smoke? 19% 24% 26% 30% (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

48. What Percentage of Pregnant Women Ages 17-18 in Nova Scotia Smoke? 24% 28% 34% 56% (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

49. What percentage of women who stop smoking during pregnancy will start again within 4 months of delivery? 25% 40% 50% 70% (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

50. Which of the following is not considered a ‘better practice’ for supporting pregnant women to stop smoking? Paying special attention to the health status of the fetus Looking at the smoking patterns of partners and family Providing follow-up following delivery Encouraging those who are heavily addicted and unable to stop smoking to consider Nicotine Replacement Therapy in the second and third trimester (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

51. One of the most significant reasons for women to relapse is lack of support from their partner, friends, and family. True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

52. Knowing what likely may cause a person to occasionally have a cigarette as well as the process for overcoming those triggers is essential to successfully stop smoking. True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

53. Using NRT during pregnancy is never considered safe a practice True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

54. If a pregnant women hasn’t stopped smoking by her 6 th month of pregnancy, there’s no point in her trying to stop True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

55. A woman who smokes should not breastfeed her baby True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

56. A person is more likely to stay away from smoking if their motivation is internal rather than external True False (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

57. Congratulations! You have completed the tutorial. To receive your Certificate of Completion, please complete a brief evaluation here.here It will only take a moment of your time and your feedback will help us to improve the tutorial for others. Thanks for taking the time to learn more about how to better support women to stop smoking during pregnancy. To see References and Glossary, click on the arrow Try Quiz Again (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

58. Additional Information Helping Women Quit: A guide for workers with not experience in supporting women to stop smoking. Alcohol and Drug Education Services (ADES), 2007. STARSS (Start Thinking About Reducing Secondhand Smoke): A guide to supporting women (low income) who smoke and their children. Action on Women’s Addictions – research and education (AWARE), 2009. CAN-ADAPTT: Provides guidelines for health and allied professionals in stop smoking programming for general and high risk populations. Centre for Addiction and Mental Health (CAMH). Stop Smoking: Cessation resources for those who work with women. Canadian Public Health Association (CPHA), 2006. Pregnets: Website dedicated to improving the health of mothers, fetuses, babies and children. CAMH. Women and Tobacco Info Pack: Explore the reasons girls and women start smoking, why they continue to smoke despite the health risks and the challenges they face when attempting to quit. Program Training and Consultation Centre (PTCC), 2010. Brief Counselling for Smoking Cessation: For individuals who want to help others quit smoking when time is limited to less than ten minutes. PTCC, 2008. Training Enhancement in Applied Cessation Counselling and Health (TEACH) Project: Trains health care professionals in the public, private and non-profit sectors who provide counselling services to people who use tobacco. CAMH. Motherisk: A clinical, research and teaching program dedicated to antenatal drug, chemical, and disease risk counseling. Hospital for Sick Children (Toronto). (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

59. References 1.Nova Scotia Reproductive Care Program, 2009. 2.Greaves et al. (2003) Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre of Excellence for Women’s Health, http://www.hc-sc.gc.ca/hc- ps/pubs/tobactabac/expecting-grossesse/index-eng.phphttp://www.hc-sc.gc.ca/hc- ps/pubs/tobactabac/expecting-grossesse/index-eng.php 3.Fang, et al. (2004) Smoking Cessation in Pregnancy: A review of Postpartum Relapse Prevention Strategies, Journal of the American Board of Family Practice, 17:265-275 http://www.jabfm.org/cgi/content/full/17/4/264http://www.jabfm.org/cgi/content/full/17/4/264 4.Berlin, I, Singleton, E. at al. (2002) The Modified Reasons for Smoking Scale: factorial structure, gender effects and relationship with nicotine dependence and smoking cessation in French Smokers. Addiction 09 (11):1575-83 http://www.biomedexperts.com/Abstract.bme/14616184/The_Modified_Reasons_for_Smoking_Scale_facotrial_structure_gender_effe cts_and_relationship_with_nicotine_dependence_an http://www.biomedexperts.com/Abstract.bme/14616184/The_Modified_Reasons_for_Smoking_Scale_facotrial_structure_gender_effe cts_and_relationship_with_nicotine_dependence_an 5.Dempsey, D., Jacob, P., & Benowitz, N.L. (2002) Accelerated metabolism of nicotine and cotinine in pregnant smokers, Journal of Pharmacology and Experimental therapeutics, (301) 594-598 http://jpet.aspetjournals.org/content/301/2/594.full.pdfhttp://jpet.aspetjournals.org/content/301/2/594.full.pdf 6.Adapted from Poole, N. & Greaves, L. (eds.) (2007). Highs & Lows: Canadian Perspectives on Women and Substance Use. Toronto: Centre for Addiction and Mental health. Copyright © 2001 British Columbia Centre for Excellence for Women’s Health http://www.camh.net/publications/camh_publications/highs_lows.html http://www.camh.net/publications/camh_publications/highs_lows.html 7.Graham, H. (2009) Why tobacco disparities matter for tobacco-control policy. American Journal of Preventative Medicine. 37:2s 8.Centre for Addictions and Mental Health (2007) Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers. http://www.camh.net/Publications/Resources_for_Professionals/Pregnancy_Lactation http://www.camh.net/Publications/Resources_for_Professionals/Pregnancy_Lactation 9.Training Guide for Smokers’ Helplines: Pregnant and Postpartum Protocols, Health Canada (2005) 10.Edwards and Sims-Jones (1998) Smoking and smoking relapse during pregnancy and postpartum: results of a qualitative study. Birth; 25:94-100 11.Stop Smoking: A Cessation Resource for Those Who Work with Women, Canadian Public Health Association, 2006 http://acsp.cpha.ca/stopsmoking/english/index_e.html http://acsp.cpha.ca/stopsmoking/english/index_e.html 12.Edwards, Sims-Jones and Holtz (1996) Pre- and post-natal smoking: A review of the literature. Publication M96-2. Ottawa, ON: University of Ottawa. 13.Dragonetti, Rosa, Presentation, Helping Pregnant Smokers Stop Smoking, RNAO Conference, January 28, 2010 14.US Department of Health and Human Services, Public Health Service (2000) Clinical Practice Guideline: Treating Tobacco Use and Dependence. http://www.surgeonegeneral.gov/tobacco/treating_tobacco_use.pdfhttp://www.surgeonegeneral.gov/tobacco/treating_tobacco_use.pdf 15.Pregnets. Clinical presentation “Smoking cessation during pregnancy.” http://www.pregnets.org/providers/toolkit/Smoking_Cessation_During_Pregnancy.pdf http://www.pregnets.org/providers/toolkit/Smoking_Cessation_During_Pregnancy.pdf 16.Greaves et al. (2005) Quit Smoking telephone Counselling Protocol for Pregnant and Postpartum Women. British Columbia’s Women’s Hospital and Health Centre. http://www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/protocol/recomm-eng.phphttp://www.hc-sc.gc.ca/hc-ps/pubs/tobac-tabac/protocol/recomm-eng.php 17.Pregnets. Questions webpage. http://www.pregnets.org/mothers/questions.aspx (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

60. Better Practices for Addressing Prenatal and Postpartum Tobacco Use Glossary Adapted from: Ontario Tobacco Research Unit (OTRU) Glossary. http://glossary.otru.org/ 5 A’s model (1) brief interventions used to provide support to help people stop smoking: Ask, Advise, Assess, Assist, Arrange (2) other brief intervention models may refer to the 3A’s or 4A’s Reference: Fiore MC, Bailey WC, Cohen SJ. Treating Tobacco Use and Dependence Clinical Practice Guidelines. Rockville, Maryland: US Department of Health and Human Services, Public Health Service; 2000 Addiction (1) compulsive use of a substance (e.g., tobacco) despite undesired consequences or a desire to stop, often accompanied by neurochemical and molecular changes in the brain; (2) by extension, compulsive performance of certain types of behaviour (e.g., gambling) despite undesired consequences or a desire to stop Reference: Kalant H, Kalant OJ. Drugs, Society and Personal Choice. Addiction Research Foundation, Toronto, 1971. Advise in the 5 A’s model, advise those who use tobacco to stop in a strong, clear, non-judgemental and personalized way Arrange in the 5 A’s model, arrange follow-up contacts to prevent the smoker from relapsing to tobacco use. As appropriate, provide written self-help materials, refer to a local program and enroll the tobacco user in telephone quit line or on-line stop smoking program Ask in the 5 A’s model, ask whether she/he has used any form of tobacco products in the last 6 months Assess in the 5 A’s model, assess her/his willingness to stop using tobacco at the present time; if the tobacco user is not willing to make a stop attempt at the present time, then try to increase motivation to stop at a later time (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

61. Assist in the 5 A’s model, assist her/him in making a stop attempt, if the tobacco user is willing to attempt to stop, provide brief counselling and as necessary assist them to access pharmacotherapy At Risk the likelihood that certain persons or groups (e.g., young adults) will engage in smoking behaviour Reference: Gilpin EA, White VM, Pierce JP. What fraction of young adults are at risk for future smoking and who are they? Nicotine and Tobacco Research 2005;7:747-759. Better Practices plausible, appropriate, evidence-based and well-executed actions and processes designed to reduce the burden of tobacco-related disease, with the idea, however, that further improvements in these practices are possible and sought Carbon Monoxide colourless, odourless toxic gas that occurs as a result of burning tobacco, which reduces the oxygen-carrying capacity of the blood and causes health problems, e.g., respiratory and cardiac malfunction, depression of the central nervous system, diarrhea, dizziness, headaches, vomiting, convulsions and delay of fetal development Cessation synonym for stopping smoking or attempting to stop smoking Reference: Norman CD, Maley O, Li X, Skinner HA. Using the internet to assist smoking prevention and cessation in schools: a randomized controlled trial. Health Psychology 2008;27(6):799-810. Cold Turkey a term borrowed from the field of heroin addiction, referring to a an abrupt attempt to stop smoking completely, usually without clinical support Comprehensive Tobacco Control Strategy multi-component plan of action addressing several different aspects of the tobacco epidemic simultaneously in order to diminish and eliminate problems caused by tobacco use on a broad scale Reference: Stephens T, Pederson LL, Koval JJ, Macnab J. Comprehensive tobacco control policies and the smoking behaviour of Canadian adults. Tobacco Control 2001;10:317-322. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

62. Conditioned response in classical conditioning, the conditioned response is the learned response to the previously neutral stimulus Cotinine is a metabolite of nicotine, can be measured in the person’s blood and indicates levels of nicotine intake Depressant a drug that lowers the activity and sensitivity of the central nervous system (see also Stimulant) Determinant of Health any event, character or behaviour that brings about a change in a health condition or other defined characteristic, e.g., smoking behaviour as a determinant of shorter life expectance Reference: Last JM (ed.). A Dictionary of Epidemiology, Oxford University Press, New York, 2001. Environmental Tobacco Smoke (ETS) Another term for Second-hand Smoke, though some tobacco control professionals prefer the term second hand smoke (see also Third-hand Smoke) Reference: California Environmental Protection Agency, State of California Air Resources Board. Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant, 2006. Evidence-Based conclusion or practice based on reliable factual information usually from scientific sources Reference: Rychetnik L, Hawe P, Waters E, Barratt A, Frommer M. A glossary for evidence-based public health. Journal of Epidemiology and Community Health 2004;58:538-545. Harm Reduction sometimes controversial approach to substance use involving a policy, strategy or intervention that assumes an unhealthy behaviour (e.g., smoking) will continue and aspires to lower the risk of adverse consequences rather than eliminate the behaviour altogether Reference: deRuiter W, Faulkner G, Cairney J, Veldhuizen S. Characteristics of physically active smokers and implications for harm reduction. American Journal of Public Health 2008; 98(5):925-931. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

63. Hydrogen Cyanide poisonous compound found in tobacco smoke that is rapidly metabolized in the liver to thiocyanate and causes confusion, dizziness, weakness, irritation of eyes, nose and skin, gastrointestinal upsets, headaches, nausea, vomiting, rapid respiration and weight loss Mainstream Smoke (1) when a person is actually smoking, tobacco smoke that is drawn from the mouth end of a smoked tobacco product during puffing (see also Second-hand Smoke, Sidestream Smoke and Third-hand Smoke); (2) when a smoking machine is being used for analytical purposes, tobacco smoke that issues from the mouth end of the smoked tobacco product Reference: Physicians for a Smoke-Free Canada (PSC). Dictionary of Tobacco Terms. Physicians for a Smoke-Free Canada, Ottawa, 2009. Motivational interviewing (MI) “MI is a directive, client-centered counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” (p. 325). Reference: Rollnick S and Miller WR. Motivational Interviewing: Preparing People to Change Addictive Behavior. The Guilford Press, New York, 1991 Nicotine naturally occurring psychoactive component of tobacco plants in the for colourless to pale yellow liquid, which turns brown on Nicotine Replacement Therapy (NRT) aid to quitting smoking which involves administration of nicotine by a method other than smoking, four types currently approved in Canada and available without a prescription, namely, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine patch Pharmacotherapy aid to stop smoking, e.g., Nicotine Replacement Therapy (NRT), Champix involving the use of a prescription or non-prescription drug (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

64. Poly-substance abuse the concurrent abuse of more than one psychotropic medication and/or illegal substance Reference: Centre for Mental Health and Addictions. Exposure toPsychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers, 2007 Postpartum Relapse woman who had stopped smoking during or before pregnancy starts smoking again after the baby is born Psychoactive affecting the mind or mood or other mental processes Psychosocial factors reflecting the influence of psychological perspective and social relations Relapse return to regular smoking after a stop attempt (see also Postpartum Relapse) Second-hand Smoke (SHS) tobacco smoke inhaled by people who are not actively engaged in smoking, which contains many harmful chemicals causing serious health problems, e.g., sudden infant death syndrome in infants, asthma and respiratory infections in children and lung cancer in adults. There is no safe level of exposure (see also Mainstream Smoke, Sidestream Smoke and Third-hand Smoke) Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/index.htm. Sidestream Smoke (1) when a person is actually smoking, all of the tobacco smoke from any part of a smoked tobacco product except what is drawn into the mouth by the person smoking (see also Mainstream Smoke, Second-hand Smoke and Third-hand Smoke); (2) when a smoking machine is being used for analytical purposes, the tobacco smoke that comes from the burning end Reference: Physicians for a Smoke-Free Canada (PSC). Dictionary of Tobacco Terms. Physicians for a Smoke-Free Canada, Ottawa, 2009. (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

65. Slip having a cigarette or two after having stopped smoking. Stimulant a drug that heightens the activity and sensitivity of the central nervous system (see also Depressant) Tar (1) sticky black residue found in tobacco smoke that contains hundreds of chemicals and causes cancer and lung damage; (2) technically, total particulate matter in tobacco smoke minus nicotine and water content Third-hand Smoke a relatively new term for the tobacco smoke particles left on surfaces, e.g., clothing, furniture, walls, after the smoked tobacco product is put out, which contains many of the toxic chemicals found in second-hand smoke and can be detected using biomarkers, e.g., cotinine in urine, including the urine of infants and children (see also Mainstream Smoke, Second-hand Smoke and Sidestream Smoke) Reference: Winickoff JP, Friebely J, Tanski SE, Sherrod C, Matt GE, Hovell MF, McMillen RC. Beliefs about the effects of “thirdhand” smoke and home smoking bans. Pediatrics 2009;123(1):e74-e79. Tobacco (1) a large-leafed plant (Nicotiana tabacum or Nicotania rustica) that contains nicotine, an addictive drug, and can be grown on all continents other than Antarctica; (2) general term for tobacco products Exit Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

66. Incorrect: The Answer is 26% According to 2009 Nova Scotia Reproductive Care Program Data – 26 percent of women in Nova Scotia smoke during pregnancy. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

67. Correct: The Answer is 26% According to 2009 Nova Scotia Reproductive Care Program Data – 26 percent of women in Nova Scotia smoke during pregnancy. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

68. Incorrect: The Answer is 80% The answer is 80%. It is also known that of the 80% of women who will try to stop smoking during pregnancy, 23-47% will stop smoking spontaneously, that is, they will stop smoking without being encouraged to do so. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

69. Correct: The Answer is 80% The answer is 80%. It is also known that of the 80% of women who will try to stop smoking during pregnancy, 23-47% will stop smoking spontaneously, that is, they will stop smoking without being encouraged to do so. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

70. Incorrect: The answer is 70-90% Relapse rates vary, but one study found that before delivery 25% of women will start smoking again, within 4 months of delivery 50% of women will start smoking again, and by one year of delivery 70-90% of women will start smoking again. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

71. Correct: The answer is 70-90% Relapse rates vary, but one study found that before delivery 25% of women will start smoking again, within 4 months of delivery 50% of women will start smoking again, and by one year of delivery 70-90% of women will start smoking again. Next (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

72. Many women who smoke during pregnant face numerous social and economic stresses. Unemployment, violence, poverty and other issues may not only blur the importance of stopping smoking, but may even create an environment where their tobacco addiction serves a benefit by providing an escape from some of the realities of their lives. It is unreasonable to request that a women stop smoking without addressing the multiple stressors that challenge a woman’s successful cessation (ie: stopping smoking). Cessation means to stop smoking or an attempt to stop smoking. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

73. Nicotine Addiction 4 During pregnancy the metabolism of nicotine may increase 5 ; this means that women may experience withdrawal symptoms more quickly. The Lung Association has more information on withdrawal symptoms. Nicotine has psychoactive and reinforcing effects; smoking cigarettes is the most efficient way to deliver nicotine to the reward centres of the brain (it takes just 7-10 seconds to reach the brain from the lungs). Behavioural conditioning: the ‘habit’ associated with smoking as a conditioned response to ‘triggers’ (eg. coffee, after a meal, feeling bored or ‘blue’, etc.) that makes staying smoke-free a challenge. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

74. Other Priorities Could include: Overwhelming life circumstances (violence, finances, etc) Poly-substance use/abuse Mental health Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

75. Over the last number of years, there has been increased attention on the status of the fetus. There is also more awareness about the health effects of smoking, drinking alcohol and drug use. This has led to a rise in negative social and legal attitudes about pregnant women, which in turn may impact on a pregnant woman’s feelings of self-worth. It is not useful or helpful to maintain the belief and attitude that smoking during pregnancy and smoking around children is child abuse. Remember, smoking is a conditioned response to the addiction to tobacco, not a “habit”. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

76. Considering the Determinants of Health 8 access to health care income and socio-economic status social inclusion and exclusion social support networks early childhood care education and literacy working conditions employment and job security housing food security and nutrition physical environments (e.g., safe water, clean air, adequate transportation systems) personal health practices and coping skills biology and genetic endowment gender culture When assessing a woman’s health before, during and after pregnancy, practitioners need a holistic approach that—in addition to substance use and mental health problems—takes into consideration the determinants of health. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

77. Postpartum Primary Focus:  Focus on the benefits not smoking has for her and the continued motivation of improving her own health Secondary Focus:  Discuss the baby as a secondary motivation for not smoking. Let her know she has done as wonderful job so far that that protecting her baby and that protecting her baby from 2 nd hand smoke is another way she can have a positive impact on her baby’s health.  Discuss the effects of second and third hand smoke.  Use the money saved from not smoking towards the costs of baby Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

78. Slips and Relapse Slips and relapse are common. Most people will make 3-10 attempts to stop smoking before they are tobacco- free. Knowing what may cause a slip or relapse and how to overcome these triggers is essential to successfully stop smoking. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

79. A Few Examples of High Risk Situations While drinking alcohol or coffee After a meal While on the telephone During stress and emotional upset (eg. the hormonal ups and downs of having a baby). For more information on additional techniques to manage parenting stress, see Loving Care: Parents and Families.Loving Care: Parents and Families In social situations Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

80. Encouraging even a modest reduction in the number of cigarettes smoked can help a woman to take steps toward stopping smoking. In addition, it can be beneficial to the fetus. Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

81. For more information on the use of NRT during pregnancy or postpartum, consult these two documents: CAN ADAPTT Guidelines – Pregnant and Breastfeeding Women Clinical Practice Guidelines from the Society of Obstetricians and Gynecologists Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

82. Roll with Resistance Accept client reluctance to change as natural. Adjust to client resistance rather than opposing it directly. Comments such as “I hear you”, “You don’t want…”, and “You wish” can help keep the conversation going. To see more examples: Applying MI: Roll with Resistance MI Videos Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

83. Correct! Source: Reproductive Care Program, 2009 Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

84. Incorrect Source: Reproductive Care Program, 2009 Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

85. Correct! Source: Reproductive Care Program, 2009 Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

86. Incorrect Source: Reproductive Care Program, 2009 Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

87. Correct! Relapse rates vary, but one study found that before delivery 25% of women will start smoking again, within 4 months of delivery 50% of women will start smoking again, and by one year of delivery 70-90% of women will start smoking again. (Dragonetti, R (January 28, 2010). Helping Pregnant Smokers Stop Smoking.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

88. Incorrect Relapse rates vary, but one study found that before delivery 25% of women will start smoking again, within 4 months of delivery 50% of women will start smoking again, and by one year of delivery 70-90% of women will start smoking again. (Dragonetti, R (January 28, 2010). Helping Pregnant Smokers Stop Smoking.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

89. Correct! Please refer to “7 Elements of a Better Practice Approach 18. (Source: Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S., & Aboussaf, D. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre for Excellence for Women’s Health.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

90. Incorrect Please refer to “7 Elements of a Better Practice Approach 18. (Source: Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S., & Aboussaf, D. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre for Excellence for Women’s Health.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

91. Correct! True – Please refer to “Engage Partner and Family” and “Integrate Social Issues & Support”. (Source: Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S., & Aboussaf, D. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre for Excellence for Women’s Health.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

92. Incorrect True – Please refer to “Engage Partner and Family” and “Integrate Social Issues & Support”. (Source: Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S., & Aboussaf, D. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre for Excellence for Women’s Health.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

93. Correct! Please refer to “Prevent Relapse; Provide Follow-Up”. (Source: Edwards and Sims-Jones (1998) Smoking and smoking relapse during pregnancy and postpartum: results of a qualitative study. Birth; 25:94-100) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

94. Incorrect Please refer to “Prevent Relapse; Provide Follow-Up”. (Source: Edwards and Sims-Jones (1998) Smoking and smoking relapse during pregnancy and postpartum: results of a qualitative study. Birth; 25:94- 100) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

95. Correct! Please refer to “Use a Harm Reduction Approach”. (Source: Health Canada (2005).Training Guide for Smokers’ Helplines: Pregnant and Postpartum Protocols. Ottawa, ON: Health Canada.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

96. Incorrect Please refer to “Use a Harm Reduction Approach”. (Source: Health Canada (2005).Training Guide for Smokers’ Helplines: Pregnant and Postpartum Protocols. Ottawa, ON: Health Canada.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

97. Correct! Please refer to “Pregnant Women’s Mistaken Assumptions”. (Source: Health Canada (2005).Training Guide for Smokers’ Helplines: Pregnant and Postpartum Protocols. Ottawa, ON: Health Canada.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

98. Incorrect Please refer to “Pregnant Women’s Mistaken Assumptions”. (Source: Health Canada (2005).Training Guide for Smokers’ Helplines: Pregnant and Postpartum Protocols. Ottawa, ON: Health Canada.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

99. Correct! Please refer to “Myths and Facts. (Source: US Department of Health and Human Services, Public Health Service (2000) Clinical Practice Guideline: Treating Tobacco Use and Dependence.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

100. Incorrect Please refer to “Myths and Facts. (Source: US Department of Health and Human Services, Public Health Service (2000) Clinical Practice Guideline: Treating Tobacco Use and Dependence.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

101. Correct! Please refer to “Asses Motivation to Change”. (Source: Dragonetti, R. (n.d.). Helping Pregnant Smokers Stop Smoking.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

102. Incorrect Please refer to “Asses Motivation to Change”. (Source: Dragonetti, R. (n.d.). Helping Pregnant Smokers Stop Smoking.) Next Question (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011

103. Breastfeeding Mothers: Women who smoke should be encouraged to: Smoke after breastfeeding her baby: The amount of nicotine in the body and in breastmilk decreases over time. The half-life of nicotine (the amount of time it takes for half the nicotine to be eliminated from the body) is 95 minutes. Smoke outside: This will reduce exposure to second-hand smoke. Research shows a strong connection between parents’ smoking and pneumonia, bronchitis and SIDS during their babies’ first year of life. Cut down on the number of cigarettes you smoke: Studies show that women who smoke 10 or fewer cigarettes per day have healthier babies than mothers who smoke more than 10 cigarettes per day. Other steps to protect the child from second-hand and third-hand smoke are: People who smoke should not sleep in the same bed as the baby: Particles from smoking (third-hand smoke) remain on the person’s hair and skin and are harmful to the baby Using a smoking jacket to smoke outside Washing hands (and face) after smoking Using all available aids to stop smoking Return to Tutorial (C) Pregnancy and Tobacco, Public Health Services, South Shore Health, South West Health, and Annapolis Valley Health, 2011