1. SMOKING IN PREGNANCY
Dr Catherine Angell

2. Plan for this session Physiology of smoking in pregnancy
Risks to the woman of smoking in pregnancy
Risks to the infant and child
Risks to mother and infant of passive smoking
Smoking behaviour in pregnancy
Reasons why women smoke during pregnancy
Changing smoking behaviour
The role of the midwife in relation to smoking

3. Write 3 words to describe how this image makes you feel
Write 3 words to describe how this image makes you feel keep hold of this for later

4. Physiology of smoking Nicotine
Tobacco leaves in cigarettes contain nicotine
Nicotine is an anti-herbivore chemical found in the nightshade family of plants
It combusts at only 95oC allowing its vapour to be released when the leaves are burned
Nicotine is absorbed through skin and membranes
It is then absorbed into the bloodstream
(Katzung et al., 2006)

5. Physiology of smoking Nicotine in the body
Nicotine circulates the body to the brain and crosses the blood-brain barrier in 7 seconds
It binds to nicotinic acetylcholine receptors
Dopamine, a ‘feel good’ neurotransmitter, is released in greater quantities
The body reduces the production of dopamine to try compensate for the raised levels
BUT the body then increases the number of receptors
As a result the body craves repeated doses of nicotine
(Katsung et al., 2006)

6. Physiology of smoking Why do people enjoy smoking? Dopamine Adrenaline
feelings of pleasure and satisfaction
Adrenaline
increased heart rate, blood pressure, respiration
release of glucose from the liver
raised blood sugar and appetite suppression
Norepinephrine
increased concentration, sharpness and arousal
Seratonin
calming, pain-killing, sedative effect
Nicotine is unique in the change in effect achieved by different doses

7. Physiology of smoking Smoking has particular health
PUBLIC HEALTH ISSUE
Smoking has particular health
implications for women
Infertility/delayed conception
Earlier menopause
Osteoporosis
Cervical cancer
Breast cancer (Odiase, 2009)
Heart attack/stroke if using oral contraceptives

8. Smoking during pregnancy
???
Researching risk of pregnancy
smoking is problematic because
Smoking habits related to social group
Poverty
Less educated
General health
Delay in seeking health care
Other risk factors ; diet, alcohol, medication, drugs
Less likely to breastfeed
Women may be reluctant to disclose level of smoking
Exposure to passive smoking
(Jarvis and Wardle, 1999)

9. Risks to the woman of smoking during pregnancy
Ectopic pregnancy
Miscarriage
Placenta praevia
Urinary tract infections
Placental abruption
Pre-term labour
Premature rupture of membranes
Haemorrhage
Inadequate breast milk production (Castles et al, 1999)
But not for:
Pre-eclampsia (Engel et al., 2008)
PIH (Yang et al., 2006)
Gestational diabetes (Wendland et al., 2008)

10. Risks to the infant Nicotine transfer to the infant
Nicotine and carbon monoxide move easily across the placenta
Nicotine and carboxyhemoglobin concentration is 10-15% higher in the fetus than in the mother
Nicotine is also carried in breast milk
(Briggs and Freeman, 2005)

11. Smoking during pregnancy
Note down as many physical effects of smoking for the FETUS
as you can

12. Risks to the infant IUGR Low birth weight Premature birth
Poorer outcomes for
pre-eclampsia
Neonatal mortality
Congenital malformations
Cardiovascular
Cleft lip and palate
Genitourinary
Talipes
Sudden infant death syndrome (SIDS)
Respiratory problems,
eg. pneumonia
Asthma
Ear nose throat problems, eg. glue ear
Undecended testes
(Edwards and King, 2007; Graham and Smith, 2007; Malik et al., 2008; Pipkin, 2008))

13. Risks to the child Obesity Asthma Respiratory disease Meningitis
Childhood cancers (linked to paternal smoking at conception)
Diabetes
Earlier menarche (start of periods) and menopause
Fertility difficulties
Delayed development
Emotional problems
Behavioural problems
More likely to be a smoker
(Gilman et al., 2008)
(Sterjfelt et al., 1986; Hofhuis et al, 2003)

14. Smoking in pregnancy

15. Smoking in pregnancy 23% in 1995 19% in 2000 17% in 2005
Smoking rates amongst pregnant women in the UK:
23% in 1995
19% in 2000
17% in 2005
(Baxter et al., 2009)
But RCM has noted concern about rises in pregnancy smoking rates since 2005

16. Why women smoke in pregnancy
Physiologically more difficult to break addiction during pregnancy...
Adaptation to pregnancy alters how nicotine is metabolised
Nicotine clearance improves by 60%
Rapid clearing results in a rapid decrease in blood nicotine levels
Women experience sharper withdrawal and increased craving
(Ebert et al., 2008)

17. Why women smoke in pregnancy
Get into pairs. Describe the history of a woman who you have cared for who was/is a smoker What factors in her life do you think may have caused her to smoke? Write these down

18. Why women smoke in pregnancy
Stress
Experience of smoking appears to offer relief from stress
Pregnancy anxiety, unplanned pregnancy
Money, work, housing
Partner, children, family
Guilt because of smoking
Women may believe smoking is better than stress for themselves, their baby and family
BUT smoking does not actually reduce stress...smoking increases stress hormones and having a cigarette generates dopamine which masks these
(Ebert and Fahy, 2007)

19. Why women smoke in pregnancy
Coping with depression and anxiety
Social reasons
Habit and lifestyle
Fitting in with partner/social group (Wakefield et al 1998)
Lack of understanding of risks
Risks of smoking distant and abstract (Graham, 1993)
Weight issues
Weight gain
Small baby=easier birth (Stillman et al., 1998)
Support from health professionals does not meet needs

20. Changing smoking behaviour
GO back to the woman whose history you described earlier
Did she try to give up?
What support did she get?
Did it appear to be successful for her?

21. Changing smoking behaviour
More women stop smoking during pregnancy than at other times in life (McBride, 2003)
33% of women stop smoking during pregnancy
(Edwards and Byrom, 2004)
BUT 25% smoke again with a year (Edwards and Byrom, 2004)
Disadvantaged women least likely to cease smoking
(McBride, 2003)
If the woman’s partner smokes she is much less likely to give up (McLeod et al 2004)

22. Changing smoking behaviour
2 major reviews
Cochrane (2004)
NICE (2009)
Concluded there was a lack of good quality evidence
Little research has identified the views of women who continue to smoke in pregnancy
Further research required

23. Changing smoking behaviour
Systematic review identified 48 trials......
Methods used for smoking cessation included:
Information about cessation schemes
Counselling
Group counselling
Peer support
Telephone support
Chemical testing and positive feedback
Fetal monitoring and feedback
Nicotine replacement therapy
Rewards and incentives (Lumley et al, 2004)

24. Changing smoking behaviour
Problems that women experience with smoking cessation advice...
Smoking viewed as a lifestyle choice not an addiction
The need to smoke is not understood
Assumption that women will want to give up smoking
‘Nagging’ and criticising
Feelings of shame and guilt
Lack of self-efficacy in pregnancy (Ebert et al. 2009)

25. Changing smoking behaviour
Research has demonstrated that the most effective programmes are:
Social support (Walsh et al, 1997)
Rewards (Donatelle et al., 2000)
Shared planning of smoking cessation care using a woman-focussed approach (Ebert and Fahy, 2000)
Combined interventions (Ebert and Fahy, 2007)

26. Role of the midwife Midwives have a public health role
Midwives see women over a prolonged period
Pregnancy represents a ‘teachable moment’
(McBride, 2003)

27. Current guidelines for health professionals:
Role of the midwife
Current guidelines for health professionals:
Ask (about smoking at every opportunity)
Advise (all smokers to stop)
Assist (the smoker to stop)
Arrange (follow up)
(Raw et al., 1998)

28. Changing smoking behaviour

29. Role of the midwife www.smokefree.nhs.uk
Difficult to translate broad policy into specific support...
NHS ‘Smokefree’ based around their own packs, telephone support and online tools
Specific pregnancy area in website

30. Role of the midwife General support for women
START Plan
S = Set a quit date.
T = Tell family, friends, and co-workers that you plan
to quit.
A = Anticipate and plan for the challenges you'll
face while quitting.
R = Remove cigarettes and other tobacco products
from your home, car, and work.
T = Talk to your doctor about getting help to quit.
(US Surgeon General Office, 2009)

31. Role of the midwife General support for women
Talk to a supporter/friend
Keep the house smoke free
Keep the car smoke free
Have the first cigarette later in the day
Make the interval between cigarettes longer
Use the money saved for something specific
Call the NHS Helpline for support and counseling (adapted from Viccars, 2008)

32. Think about the woman in the first slide again...

34. What words would you use to describe the image now
What words would you use to describe the image now? Would you feel better equipped to offer support?

35. Thank you!
Dr Catherine Angell

36. Useful references
Baxter, S., Blank, L.,Guillme, L., Messina, J., Everson Hock, E., Burrows, J., (2009) Systematic review of how to stop smoking in pregnancy and following childbirth. London, NICE. Briggs, G., Freeman, R., (2005) Drugs in Pregnancy and Lactation. Oxford, OUP. Ebert, G., Fahy, K., (2007) Why do women continue to smoke in pregnancy? Women and Birth, 20 (1) Ebert, L., Riet, P., Fahy, K., (2008) What do midwives need to understand/know about smoking in pregnancy. Women and Birth, 22 (1) Lumley J, Oliver SS, Chamberlain C, Oakley L (2008) Interventions for promoting smoking cessation during pregnancy. The Cochrane Library. London, Wiley. NHS (2009) Smoking in pregnancy. Available from [accessed Jan 2010]