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SMOKING IN PREGNANCY Dr Catherine Angell. Plan for this session Physiology of smoking in pregnancy Physiology of smoking Risks to the woman of smoking.

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Presentation on theme: "SMOKING IN PREGNANCY Dr Catherine Angell. Plan for this session Physiology of smoking in pregnancy Physiology of smoking Risks to the woman of smoking."— Presentation transcript:

1 SMOKING IN PREGNANCY Dr Catherine Angell

2 Plan for this session Physiology of smoking in pregnancy Physiology of smoking 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......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 95 o C 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 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 implications for women Infertility/delayed conception Earlier menopause Osteoporosis Cervical cancer Breast cancer (Odiase, 2009) Heart attack/stroke if using oral contraceptives PUBLIC HEALTH ISSUE

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 rates amongst pregnant women in the UK: 23% in % in % 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 womans 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 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 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? 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]

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