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Smoke-Free Families National Program Office 1 Smoke-Free Pregnancies Collaborating Organizations Centers for Disease Control & Prevention Robert Wood Johnson.

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Presentation on theme: "Smoke-Free Families National Program Office 1 Smoke-Free Pregnancies Collaborating Organizations Centers for Disease Control & Prevention Robert Wood Johnson."— Presentation transcript:

1 Smoke-Free Families National Program Office 1 Smoke-Free Pregnancies Collaborating Organizations Centers for Disease Control & Prevention Robert Wood Johnson Foundation’s Smoke-Free Families Program American College of Obstetricians & Gynecologists Agency for Health Care Policy and Research Health Resources and Services Administration

2 Smoke-Free Families National Program Office 2 Dangers of Smoking Before, During and After Pregnancy

3 Smoke-Free Families National Program Office 3 What’s in a Cigarette? Blended tobacco plus: l Artificial milk chocolate l Artificial tobacco flavor l Licorice flavor l Fructose syrup l Molasses l Sucrose l Vanilla l Casing l Cedarwood oil l Ethanol l Invert sugar l Isovaleric acid l Glycerol l Hexanoic acid l Methanol l Olibanum oil l Patchouli oil l Phenylacetic acid l Propylene glycol l Valerian root l Vanillin l Vetiver oil l 3-methylpentanoic acid

4 Smoke-Free Families National Program Office 4 Smoking before Pregnancy l Decreased ovulation l Impaired tubal transport l Reduced sperm count and motility l The greater the number of cigarettes smoked, the greater the effect on fertility

5 Smoke-Free Families National Program Office 5 Smoking during Pregnancy Adverse Outcomes l Preterm birth l Growth retardation l Low birthweight l Sudden Infant Death Syndrome (SIDS) l Childhood illness l School problems

6 Smoke-Free Families National Program Office 6 Smoking during Pregnancy Pregnancy Outcomes Outcome Effect Mean Gestational AgeLittle or None Preterm BirthRR = 1.4 Growth RetardationRR = 2.4 Mean Birth weight- 149 grams A small proportion of preterm births, but 36% of all growth retardation is attributable to smoking. Kramer, 1987

7 Smoke-Free Families National Program Office 7 Smoking during Pregnancy Risk Factors In the developed world, cigarette smoking is the most powerful known determinant of fetal growth retardation. The relationship between smoking and low birthweight is one of the most consistent findings in the epidemiologic literature. Stein & Susser

8 Smoke-Free Families National Program Office 8 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

9 Smoke-Free Families National Program Office 9 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

10 Smoke-Free Families National Program Office 10 Smoking during Pregnancy Growth Retardation in Developed Countries-- Risk Factors Kramer, WHO Bulletin, 1987 (36%)

11 Smoke-Free Families National Program Office 11 Smoking during Pregnancy Low Birthweight 01-56-1011-1516-2021-3031+ Cigarettes per Day Simpson, Am J OBGYN, 1957

12 Smoke-Free Families National Program Office 12 Smoking during Pregnancy SIDS l Maternal smoking during pregnancy has been associated with a 2-4 fold increased risk of SIDS l Maternal postpartum smoking and smoking by others in the household has also been associated with SIDS

13 Smoke-Free Families National Program Office 13 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

14 Smoke-Free Families National Program Office 14 Smoking during Pregnancy Long-Term Effects on Children l Decreased IQ –Lower scores on spelling and reading tests l Poorer school performance –Shorter attention span –More likely to be hyperactive l Decreased height

15 Smoke-Free Families National Program Office 15 Smoking during Pregnancy Long-Term Effects on Children Children of mothers who quit smoking during pregnancy scored 5 points higher on IQ tests and had better motor skills compared to those whose mothers did not quit. Sexton, 1990

16 Smoke-Free Families National Program Office 16 Which Women Smoke?

17 Smoke-Free Families National Program Office 17 Risk Factors For Smoking l Low Education l Young Age l White Race l Medicaid Recipient l Partner Who Smokes

18 Smoke-Free Families National Program Office 18 Smoking during Pregnancy By Education Less than High School26% High School Graduate18% Some College11% College Graduate3%

19 Smoke-Free Families National Program Office 19 Smoking in Grade School USA 1975-1996 1 or more cigs. last 30 days

20 Smoke-Free Families National Program Office 20 Smoking Among Pregnant Women United States, 1965-1996 Final Natality Statistics, 1989-1996

21 Smoke-Free Families National Program Office 21 Smoking during Pregnancy By Race and Ethnicity United States, 1996 Final Natality Statistics, 1996 21% 17% 10% 4% 3%

22 Smoke-Free Families National Program Office 22 Who Smokes before Pregnancy By Source of Care and Payment SourcePercent Health Department60% Medicaid (Any Source) 60% Private MD and Insurance 30% Adams from PRAMS

23 Smoke-Free Families National Program Office 23 Smoking during Pregnancy By Employment Status

24 Smoke-Free Families National Program Office 24 Smoking Prevalence in the USA JAMA, 1989:261

25 Smoke-Free Families National Program Office 25 Smoking Among Women In 1994, more than 14 million U.S. women aged 15-45 years were smokers. 800,000 to 1,000,000 of these women become pregnant each year.

26 Smoke-Free Families National Program Office 26 Smoking during Pregnancy Long-Term Effects on Woman Increased Decreased Cancer Life expectancy Heart Disease Chronic Lung Disease Stroke

27 Smoke-Free Families National Program Office 27 142,000 Deaths Attributable to Cigarette Smoking in Women - United States, 1990 CDC, MMWR, 8-27-93 CDC, MMWR, 8-27-93 Ischemic Heart DiseaseLung Cancer Stroke Chronic Lung Disease Other Diagnoses Other Cancers

28 Smoke-Free Families National Program Office 28 Diagnosis of Smoking

29 Smoke-Free Families National Program Office 29 Diagnosis of Smoking Deception rates, as confirmed by comparing results of biochemical tests with self-reports, are high. They may reach 50% in some populations. Alabama SCIP, 1998

30 Smoke-Free Families National Program Office 30 Diagnosis of Smoking l Biologic markers are the gold standard for diagnosing smoking or documenting cessation. l A structured questionnaire correlates better with biologic markers than does asking a pregnant woman if she smokes and how much.

31 Smoke-Free Families National Program Office 31 Diagnosis of Smoking Biological Markers: ThiocyanateCotinine Carbon Monoxide Urine or Saliva Measured in: Expired air

32 Smoke-Free Families National Program Office 32 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

33 Smoke-Free Families National Program Office 33 Cessation and Treatment Programs

34 Smoke-Free Families National Program Office 34 Spontaneous Cessation l Between 10 and 40% of pregnant smokers quit spontaneously. l The percentage depends on the mother’s age, race, education, duration and level of smoking.

35 Smoke-Free Families National Program Office 35 Self-Initiated Rates of Cessation among Pregnant Women l 40% of pregnant women who are privately insured quit smoking before their first prenatal visit l 20% of pregnant women who are covered by Medicaid quit smoking before their first prenatal visit Windsor, Li, Lowe, et al., 1993 Ershoff, Mullen, Quinn, 1989

36 Smoke-Free Families National Program Office 36 Spontaneous Quitters l Are less addicted l Appear to be more concerned about effect of smoking on baby l Have more years of school

37 Smoke-Free Families National Program Office 37 Smoking during Pregnancy Possible Interventions l Clinical: cessation counseling & pharmacotherapies l Community-based: mass media education l Policy: tobacco taxes

38 Smoke-Free Families National Program Office 38 Smoking Cessation during Pregnancy Message from the Field “We are funded and very anxious to do a smoking cessation program for pregnant women, but we don’t know what to do.” Healthy START Program Syracuse, NY, October 1998

39 Smoke-Free Families National Program Office 39 Smoking Cessation during Pregnancy Clinical Cessation Programs Many different interventions have been used in an attempt to reduce or eliminate smoking in pregnancy: l Physician Advice l Self-help manuals and other printed materials l Video-tapes l Group clinics l Psychotherapy

40 Smoke-Free Families National Program Office 40 Smoking Cessation during Pregnancy Clinical Cessation Programs l Many methods have not been tested rigorously in randomized trials. l Most tested methods have not produced a significant increase in cessation.

41 Smoke-Free Families National Program Office 41 Smoking Cessation during Pregnancy Best Clinical Practice Meta-analyses reviewing smoking cessation studies have concluded that: For women smoking at the first prenatal visit, the provision of a single 5-15 minute counseling session by a trained provider plus appropriate print materials can increase cessation rates from 5-10% to 15-20%.

42 Smoke-Free Families National Program Office 42 Smoking Cessation during Pregnancy 5-15 Minute Counseling Session l Determine amount smoked l Review smoking-associated risks to fetus, infant and mother l Review benefits to cessation l Teach methods to stop smoking l Ask for commitment to stop smoking l Ask for commitment to use self-help manual

43 Smoke-Free Families National Program Office 43 Smoking Cessation during Pregnancy 5-15 Minute Counseling Session The 5-15 minute counseling session appears to work equally well with women of various ethnic and racial groups.

44 Smoke-Free Families National Program Office 44 Smoking Cessation during Pregnancy Cessation Programs l In pregnancy, less intensive advice has not significantly increased cessation over background. l In pregnancy, more intensive interventions have generally not increased cessation rates above those achieved using a 5-15 minute counseling session by a trained provider.

45 Smoke-Free Families National Program Office 45 Smoking Cessation during Pregnancy Current Barriers l They question the effectiveness of counseling l There are no specific ACOG recommendations l Their staffs are untrained in this area l There are too many intervention choices l There is no reimbursement for counseling Other than advice to quit, most obstetric providers do not include smoking cessation counseling among their services because:

46 Smoke-Free Families National Program Office 46 Smoking Cessation during Pregnancy Print Materials l Adverse effects of smoking on pregnancy l Techniques to help quitting l Benefits to be gained from quitting and for reducing smoking Print materials should be tailored for pregnancy and should present:

47 Smoke-Free Families National Program Office 47 Smoking Cessation during Pregnancy Provider Training l A non-physician provider (nurse/ nutritionist/social worker/etc.) can be trained and certified on site to screen and counsel using self-instructional educational/training materials. l The total time needed for this training is less than 3 hours.

48 Smoke-Free Families National Program Office 48 Implementing Cessation Programs Lessons Learned l Execution matters l Systems matter l Incentives (to providers) work The Guide to Community Preventive Services

49 Smoke-Free Families National Program Office 49 Implementing Cessation Programs in MCOs 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

50 Smoke-Free Families National Program Office 50 Cessation Programs Cost - Effectiveness Using the 5-15 minute counseling session plus print materials, various investigators have estimated that there will be a $3 reduction in medical costs for every $1 spent on the intervention.

51 Smoke-Free Families National Program Office 51 Smoking Cessation during Pregnancy The 5-15 minute counseling intervention has not significantly increased smoking cessation in heavy smokers.

52 Smoke-Free Families National Program Office 52 l In non-pregnant smokers, both NRT (patch, gum, inhaler) and antidepressants (buproprion) approximately double cessation compared to behavioral methods. l In very limited studies in pregnant women, NRT was not associated with adverse outcomes, but did have a short-term influence on fetal breathing movements and fetal heart rate variability.

53 Smoke-Free Families National Program Office 53 There are no existing studies in which the safety or efficacy of either antidepressants or NRT has occurred in a sufficiently large pregnant population to determine what might occur with large-scale use.

54 Smoke-Free Families National Program Office 54 S moking Cessation during Pregnancy Pharmacologic Interventions 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. l The efficacy and safety of these pharmacological approaches during pregnancy is unknown.

55 Smoke-Free Families National Program Office 55 Smoking Cessation during Pregnancy Pharmacologic Methods l Nicotine Replacement Therapy (NRT) l Buproprion/Zyban

56 Smoke-Free Families National Program Office 56 Why Offer a Smoking Cessation Program during Pregnancy?

57 Smoke-Free Families National Program Office 57 Substance Use in Past Month Among Women Aged 15-44 Years National Household Survey on Drug Abuse, 1994-1996 National Household Survey on Drug Abuse, 1994-1996 20.6% 2.4% 2.7%

58 Smoke-Free Families National Program Office 58 Smoking Cessation during Pregnancy Stopping smoking is one of the few preventive measures likely to have a substantial impact on pregnancy outcome.

59 Smoke-Free Families National Program Office 59 Smoking Cessation during Pregnancy Pregnant smokers who stop smoking at any time up to the 30th week of gestation have infants with higher birthweight than women who smoke throughout pregnancy.

60 Smoke-Free Families National Program Office 60 Smoking Cessation during Pregnancy Reductions in cigarette smoking documented by a decrease in cotinine or other biologic markers, or by self-report, have been associated with an increase in birth weight.

61 Smoke-Free Families National Program Office 61 Smoking Cessation during Pregnancy Smoking cessation can also result in a permanent change in life-style that will reduce the risk of smoking-related chronic diseases.

62 Smoke-Free Families National Program Office 62 Postpartum Smoking Cessation Mullen, 1990

63 Smoke-Free Families National Program Office 63 Smoking Cessation during Pregnancy Postpartum Maintenance l Woman’s health l Next pregnancy l Child’s health Up to 35% of women who stop smoking during pregnancy remain nonsmokers, benefiting :

64 Smoke-Free Families National Program Office 64 Smoking Cessation during Pregnancy Reduction of Medical Care Costs l Direct health care costs –prenatal –delivery –postnatal l Indirect costs –years of life lost--infant mortality –lost productivity of mother

65 Smoke-Free Families National Program Office 65 Smoking Cessation during Pregnancy Reduction of Medical Care Costs l The excess cost of neonatal care for the infant of a smoker averages $500 l Prenatal smoking interventions may yield a benefit-cost ratio of 3:1 for the initial hospital stay and 6:1 using a longer time frame l The break even point of prenatal smoking interventions is estimated to cost $32-$80

66 Smoke-Free Families National Program Office 66 The Future

67 Smoke-Free Families National Program Office 67Goal Achieve widest possible utilization by providers of an officially endorsed, pregnancy- specific, smoking cessation intervention

68 Smoke-Free Families National Program Office 68 Next Step l Private providers l Public providers l Managed care providers Develop a dissemination strategy to achieve maximum utilization of the intervention by:

69 Smoke-Free Families National Program Office 69 Smoking Cessation during Pregnancy Dissemination Goal Dissemination by the CDC and other federal agencies, ACOG, and the RWJF Tobacco Control initiatives has the potential to achieve a nationwide adoption of a single, pregnancy-specific, smoking cessation intervention to be delivered by all providers, thereby setting the standard of care for pregnant smokers.


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