Smoking Cessation during Pregnancy and Lactation Alice Ordean MD, CCFP, MHSc Medical Director, T-CUP, SJHC November 30, 2011

Outline Prevalence of tobacco use during pregnancy Effects: obstetrical, fetal, neonatal, adolescence Screening and assessment for nicotine dependence Smoking cessation interventions during pregnancy Tools and resources

Prevalence of smoking during pregnancy 22% of women report smoking in the 3 months prior to pregnancy or before becoming aware of pregnancy (16% smoking daily, 6% occasionally) Proportion of women who smoked during pregnancy declined to ~11% in third trimester (7% smoked daily & 4% occasionally) Proportion of daily smokers who smoked 10+ cig/day declined during pregnancy & increased again postpartum Daily smokers in T3: 58% smoked 1-9 cig/day, 42% smoked >10 cig 80% of women try to quit or reduce smoking Ref: Canadian Maternity Experiences Survey, 2009 Reference: The Canadian Maternity Experiences Survey, 2009 Population for survey: birth mothers 15 years of age and older who had a singleton live birth in Canada during 3 month period preceding the 2006 Canadian Census of Population & who lived with their infant at the time of data collection

Prevalence of smoking during pregnancy (2) 47% of those who quit during pregnancy had resumed smoking by 6 months postpartum – overall 16% were smoking after delivery (12% daily, 4% occasionally) During pregnancy, 23% of women lived with someone who smoked Reasons for smoking postpartum: stress mgmt, time for herself, losing weight -Proportion of women smoking postpartum remained lower than prior to pregnancy

Characteristics of women who smoke during pregnancy Younger age: <24 years old Educational level: less than high school education Multiparity Low socioeconomic status: Women living in a household at or below the low income cut-off Marital status: single mothers Variations by provinces & territories Ref: Canadian Maternity Experiences Survey, 2009 Characteristics of women who reported regular (daily or occasionally) smoking during pregnancy -55% of younger mothers (15-19 yrs) reported smoking daily or occasionally -47% of women with less than a high school education reported smoking either daily or occasionally compared with 8% of women with a university degree -multiparous women were more likely to smoke during pregnancy than primiparous women; women were less likely to smoke during first pregnancy compared to subsequent pregnancies -20% of women living in a low income household smoked during pregnancy compared to 8% of women living in a household above low income cut-off -single mothers (with limited supports) rely on smoking as a coping mechanism and as a way to claim personal space

Pregnancy-related effects of maternal smoking Dose-response relationship documented: effects influenced by amount & duration of smoking Increased risk of : Spontaneous abortion -1.5x, ectopic pregnancy Intrauterine growth restriction (IUGR) – 2x Preterm delivery, premature rupture of membranes Placental complications (placenta previa, placental abruption) 2x Infant morbidity & mortality (eg. stillbirth) mostly due to increased IUGR and preterm delivery Ref: www.pregnets.org Evidence from a recent systematic review and meta-analysis demonstrated negative perinatal outcomes (e.g. trend towards lower birth weight, smaller head circumference and congenital anomalies) associated with second-hand smoke exposure. Therefore, pregnant and breastfeeding women should avoid this environmental risk Ref: www.pregnets.org 2. DiFranza JR et al. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004; 113(4): 1007-1015.

Breastfeeding Products of tobacco smoke are concentrated in breast milk (up to 5x greater than in blood) Smoking can decrease quality & quantity of breast milk by inhibiting milk let-down  feeding difficulties and early weaning from BF Breastfeeding is protective against respiratory illnesses  BF is encouraged among smokers Nicotine levels increase after smoking; half-life of nicotine is 95 minutes  women should avoid smoking just before and during feeding Notes: -half-life: amt of time for half the nicotine to be eliminated from the body -bottlefed infants have much higher incidence of respiratory illnesses than breastfed infants -risks of not breastfeeding are greater to baby than risks of breastfeeding and smoking -mothers should be encouraged to not smoke and parents must be advised of potential risks of env. Tobacco smoke exposure to their child including potential for future addiction to smoking Ref: Becker AB et al. Breastfeeding and environmental tobacco smoke exposure. Arch pediatr adolesc med 1999; 153: 689-691.

Neonatal & Childhood effects Effects linked to maternal smoking during pregnancy and second-hand smoke exposure Increased risk of: More cranky or colicky babies Sudden infant death syndrome 2-5x Respiratory illnesses eg. bronchitis, pneumonia Asthma & allergies up to 400x Middle ear infections Neurodevelopmental (eg. poorer math & reading skills) & behavioural problems (eg. attention- deficit/hyperactivity disorder)

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

Reasons for Screening during Pregnancy Cigarette smoking during pregnancy and breastfeeding is associated with numerous negative effects – preventable outcomes by cessation of smoking at any point during pregnancy Pregnancy represents a window of opportunity to help woman make a change

Who is more likely to quit? Women with the following characteristics are more likely to quit smoking: higher educated lighter smokers those who live with nonsmokers those with stronger beliefs in the harms of smoking those experiencing their first pregnancy Source: Stewart et al, 1994

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

Smoking Cessation Strategies in Pregnancy Offer a variety of cessation approaches and intensities depending on stage of change Address the postpartum period in the prenatal intervention Build-in partner support Encourage smoking reduction as an alternative to smoking cessation for those unable to quit Ref: www. Pregnets.org

Screening ASK: “Do you smoke? How many cigarettes do you smoke?” If she does not smoke, inquire about environmental tobacco exposure “Does anyone smoke around you or your children?” If yes, then educate about ways to stop or decrease exposure to second hand smoke

Screening (2) Assess motivation/readiness to change behaviour Ask: “How do you feel about your smoking? Are you planning to quit?” “On a scale of 1-10 how would you rate your motivation to quit smoking at this time? “On a scale of 1-10, how important is it for you to quit at this time?” “On a scale of 1-10, how confident are you that you can quit smoking at this time?”

STAGES OF CHANGE Precontemplation Contemplation Relapse Progress Preparation Action STAGES OF CHANGE IN PREGNANCY PREGNANCY is a window of opportunity to make a change!!! Women often expected to jump from precontemplation/contemplation to action immediately Often present as action, due to societal pressures Can be more fluid Smokers make 3-4 quit attempts over 7-10 years before achieving long-term abstinence  repeated intervention may be required Maintenance

Stages of Change Pre-contemplative: no interest in quitting, or “in more than 6 months” Contemplative: thinking about quitting in 1-6 months Preparation: planning to quit in next month Action stage: in process of cutting down or has set a quit date Maintenance: quit more than 6 months ago

Assessment Amount & duration smoked (pack-years), pattern of smoking Degree of dependence eg. Fagerstrom test – time from waking up to first cigarette Reasons for smoking and for quitting Past experience with quitting: what worked and what did not, relapse triggers Other addictions, medical problems, psychiatric problems, medications Fagerstrom test for nicotine dependence: gold std for assessment of tobacco addiction -to determine level of nicotine dependence -6 questions, scored individually, score out of 10 -single factor most strongly associated with degree of nicotine dependence: How soon after you wake up do you smoke your first cigarette? -score interpretation: 0-2: very low level of nicotine dependence 8-10: very high level of nicotine dependence

Smoking Cessation Management 1. Counselling: tailor intervention according to stage of change & focus on moving patients along stages of change and enhancing confidence to quit 2. Pharmacotherapy: suppress withdrawal symptoms & cravings Nicotine replacement therapies Bupropion (Zyban) Varenicline (Champix) Efficacy improves with treatment intensity, but brief interventions are also effective

Smoking Cessation Counselling Smoking cessation should be encouraged for all pregnant, breastfeeding and postpartum women A smoke-free home environment should also be encouraged to avoid exposure to second- hand smoke Counselling is recommended as first line treatment for smoking cessation during pregnancy and breastfeeding (some evidence for increased quitting rates) Donovan JW, 1977 RCT Results: intensive individual anti-smoking advice given in parallel with hospital antenatal care associated with reduction in smoking soon after counselling started but little further reduction after 28 wks GA & did not influence outcome of pregnancy Stotts AL et al., 2002 Prospective RCT of intensified late pregnancy smoking cessation intervention (3-5 min of counselling plus a self-help booklet at first prenatal visit, then 7 booklets mailed weekly) for resistant pregnant smokers Results: no differences among groups at 3 and 6 months postpartum Rigotti NA et al., 2006 RCT of proactive pregnancy-tailored telephone counseling for smoking cessation vs. brief-counseling controls Results: No difference in abstinence rates at 3 months postpartum; only effective for light smokers and in women who had attempted cessation earlier in pregnancy Melvin CL et al., 2000 Meta-analyses Result: Brief cessation counselling session of 5-15 minutes delivered by a trained provider along with pregnancy specific self-help materials sig. increases rates of cessation among pregnant smokers Lumley et al., 2009 Cochrane database of systematic reviews- RCTs or quasi-randomized trials Results: RCT of smoking cessation programs during pregnancy was associated with a sig. reduction in smoking , reduction in low birth weight and reduction in preterm birth

Goals of Counselling Stage of change Intervention Pre-contemplative Initiate discussion about impact of smoking on patient’s life, encourage smoke free house/car & provide educational materials Contemplative Increase motivation to quit: offer help, complete decisional balance – pros & cons of smoking and quitting Preparation Help find right treatment: plan for quitting eg. past quit hx, barriers & smoking triggers, set quit date Action Support & sustain cessation efforts: coping strategies , medications, follow-up visits Maintenance Relapse prevention counselling Ref: 1. Pegasus healthcare international publciation. Smoking cessation guidelines, 2000. 2. CAMH addiction toolkit: smoking cessation, 2010.

Components of Counselling Interventions Counselling: brief, delivered by range of practitioners; may be conducted by physicians, allied healthcare professionals (e.g. social worker, pharmacist), family home visitors, etc. Quit guides: take-home, patient-focused guide to quitting Buddy support: to provide social support Partner counselling/social context Education about pregnancy & smoking

Managing the Environment During Pregnancy Make no-smoking rules for her home Handling the challenge of partner smoking Avoid triggers & remove “reminders” Postpartum Explain to others that the same no-smoking rules apply as in pregnancy Ref: www.pregnets.org

Managing Cravings Be aware of what’s happening: discuss what she enjoyed about smoking vs. non-smoking Be prepared to resist it: change past routines Remember that it will not last long Use a non-smoking alternative whenever feel the need to smoke eg. exercising, chewing gum, eating, using relaxation skills & other enjoyable activities eg. phoning a friend Avoid other substances eg. coffee, alcohol

Managing difficult situations (“slips”) Assure patient that slips and relapses are normal: learning opportunity, not a failure Identify triggers & develop a plan to cope with them Maintain motivation and encourage positive self-talk to maintain self-confidence Strengthen commitment Get back on track

Partner/Family Involvement Partners, friends & family members should also be offered smoking cessation interventions Despite preliminary evidence that continued smoking and relapse are more likely among pregnant women who have a smoking partner, there is limited data regarding the benefits of partner involvement in smoking cessation interventions for pregnant smokers In non-pregnant populations, interventions to increase support did not find increased quitting rates

Pharmacological Support Second-line treatment options during pregnancy may include: Nicotine replacement therapies Bupropion (Zyban) Varenicline (Champix)

Nicotine Withdrawal Symptoms increase by 3-4 days after quitting smoking and last for 1 week First symptoms: dysphoric or depressed mood, irritability, restlessness, anxiety, insomnia, fatigue, increased appetite Lack of concentration and cravings may last for months Symptoms worse in heavy smokers and those who smoke within 30 minutes of getting up

Nicotine Replacement Therapies (NRT): Clinical Considerations NRT can be considered as a second line option for individuals who cannot quit after counselling interventions Intermittent dosing nicotine replacement therapies (such as lozenges/gum) are preferred over continuous dosing of a patch There is limited evidence on harms associated with the use of nicotine replacement therapy (NRT) during pregnancy

NRT (2): Clinical Considerations Evidence from RCTs failed to find a difference in smoking cessation rates, but there may be some decrease in number of cigarettes smoked per day & improved pregnancy outcomes (lower rates of preterm delivery & low birth weight) Benefits of NRT seems to outweigh potential risks; therefore, NRT should be considered when counselling has been ineffective. Ref: Forrest S. Amer J of Maternal Child Nursing, 2010. Lumley et al., 2004 3 RCTs of NRT in pregnant smokers provide no conclusive evidence of this effectiveness in this particular group. Meta-analysis of these 3 trials did not show a significant effect of NRT use in pregnancy. Pollak et al., 2008 RCT of NRT + CBT vs. NRT only Result: cessation rates during pregnancy 3x higher in CBT+NRT arm, but difference did not persist postpartum Onkhen et al., 2008 RCT: nicotine gum vs. placebo; both received behavioural counselling Results: No increase rate of smoking cessation; women who received nicotine gum during pregnancy had a significant reduction in number of cigarettes smoked per day

Bupropion (Zyban) Depression during pregnancy is a common occurrence and the use of Zyban (bupropion) may be appropriate to treat both smoking and depression There is limited evidence on the effectiveness of bupropion for smoking cessation during pregnancy; only 1 prospective study demonstrated increased quitting rates with bupropion use during pregnancy Boshier A et al., 2003 Observational cohort study Results: No significant difference in mortality ratio Chan B, Einarson A, and Koren G, 2005 Prospective matched, controlled observational study Results: Greater number of pregnant women quit in bupropion group Chun-Fai-Chan B et al., 2005 Prospective case-control study Results: no association between bupropion exposure during pregnancy and increased risk fo major malformations Higher rate of spontaneous abortions in exposed group – unclear if outcome associated with medication or depression (illness itself)

Bupropion (2) In addition, there is no evidence of harm related to the use of bupropion during pregnancy and therefore, it may be considered for use as an alternative to NRT for a subpopulation of pregnant smokers.

Varenicline (Champix) No evidence regarding safety of varenicline during pregnancy; therefore, its use during pregnancy is not recommended.

Summary: 4 A’s ASK Smoker ADVISE to quit or reduce smoking ARRANGE follow-up ASSIST by providing brief interventions or making referral Non-smoker ASK about second-hand smoke exposure

Provider Tools/Resources PREGNETS www.pregnets.org [specialized toolkit to address smoking cessation among pregnant & postpartum women] CAN-ADAPTT www.can-adaptt.net [evidence- based clinical practice guidelines] TEACH (Training enhancement in applied cessation counselling and health)“Helping Pregnant Smokers Stop Smoking: An Interactive Case Based Course [evidence- based training and continuing professional education] CAN-ADAPTT (canadian action network for the advancement, dissemination and adoption of practice-informed tobacco treatment)

Patient Tools/Resources (2) CAMH Nicotine Dependence Clinic www.camh.net Ontario Smokers Helpline 1-877-513-5333 Motherisk www.motherisk.org or 1-877- 327-4636

CAN-ADAPTT Clinical practice guideline & knowledge exchange network Integrates practice, policy and research in a collaborative smoking cessation network Goal: To inform the development of a Pan- Canadian clinical practice guideline (CPG) for smoking cessation Dr. Peter Selby, Principal Investigator, CAN-ADAPTT Funded by the Drugs and Tobacco Initiatives Program, Health Canada

Pregnant and Breastfeeding Women Smoking cessation should be encouraged to all pregnant and breastfeeding women. (GRADE = 1A) During pregnancy and breastfeeding, counselling is recommended as first line treatment for smoking cessation.  (GRADE = 1A) If counselling is found ineffective, intermittent dosing nicotine replacement therapies (such as lozenges, gum) are preferred over continuous dosing of the patch after a risk-benefit analysis. (GRADE = 1C) Partners, friends and family members should also be offered smoking cessation interventions. (GRADE = 2B) A smoke-free home environment should be encouraged for pregnant and breastfeeding women to avoid exposure to second-hand smoke. (GRADE: 1B)

Contact Durham Health Connection Line 905-666-6241 or 1-800-841-2729 Durham Region Health Department provides a number of services to promote and support tobacco-free living DRHD offers: A 6-week Support Group for smokers that want to quit using tobacco Telephone counselling Quit Kits for prenatal and postpartum women that contain self-help materials Information for new dads regarding quitting smoking and second-hand smoke Assistance for health care providers to develop comprehensive tobacco cessation strategies for their setting Information and resources regarding community supports available to facilitate tobacco cessation Contact Durham Health Connection Line 905-666-6241 or 1-800-841-2729

HKPR District Health Unit Health Unit Actions: Knowledge & skill training for all Chronic Disease & Family Health Department Staff Implement 4A protocols Information Request Line Prenatal Programs Healthy Babies Healthy Children Post-partum Enhancement Program Integrated into continuum of care for follow-up (family home visitors & family health nurses) Focus on increasing access to cessation services by developing community capacity to provide brief interventions in a variety of settings All staff in the Chronic Disease & Injury Prevention Department and the Family Health Department are trained in implementing the 4A protocols using a motivational approach. HKPR distributes a Prenatal Health Questionnaire through local obstetricians, nurse practitioners, Family Health Teams, sexual health clinics, etc. Completed questionnaires are returned to the Health Unit (about 65% compliance). When consent is granted, follow up contact is initiated and tobacco use addressed. As part of the Healthy Babies Healthy Children Program, all participants are regularly screened and tobacco use is addressed primarily through use of the 4A protocol and referral to community resources. Identification of tobacco use during post-partum enhancement phone calls and visits is similarly addressed.

HKPR District Health Unit Partners with local health care professionals to: Provide training & technical assistance to develop community capacity to provide interventions Increase awareness of evidence-based cessation initiatives Motivate local practitioners to implement evidence-based strategies (eg. 4A Protocol) Increase the number of people contemplating, preparing & taking action to quit (particularly among youth, young men, & people with low SES) HKPR District Health Unit offers training and technical assistance to community partners. The QUITT (Quick, Understandable Intervention Techniques for Tobacco) Program is guided by OPHS 2008, Tobacco Guidance Document & TEACH materials. QUITT offers a menu of options: full day workshop, half day workshop, ‘Lunch & Learn’ workshops, self-study modules and mobile in-service in clinical settings. More than 800 local professionals (health care & social service) have participated in local training opportunities. We also refer local professionals to other opportunities for knowledge & skill enhancement (TEACH, CAN-ADAPTT, You Can Make It Happen, etc.) Examples of training participants: Local hospitals, Community Health Centres, Family Health Teams, Nurse Practitioners, Employment Counsellors, Social Workers,

Peterborough County-City Health Unit One to one individual counselling appointments Quit smoking groups Telephone counselling Provision of self-help resources Funded by Health Canada to March 2012 Clients can self refer or be referred by health care provider Fax referral can be completed and PHN will follow up proactively *1:1 counselling *Quit Groups – ECHO GROUP October 13th *Telephone Counselling *Self-help resources e.g. CCS resources, Quit Kits

Peterborough County-City Health Unit Support group for pregnant and post partum women who smoke Facilitated by a Community Health Worker and Public Health Nurse Free Childcare Free transportation $20 Gift card every week Funded by ECHO: Improving Women’s Health In Ontario to March 2013

The Canadian Cancer Society Smokers’ Helpline Free, confidential phone, online and text messaging services at 1 877 513-5333 and SmokersHelpline.ca English, French and interpreter service Accept Fax Referrals from health care providers through Quit Connection program (www.smokershelpline.ca/refer) Specialized protocols in place to serve pregnant and post- partum women Ann Burke 705-726-8032 ext. 3226 aburke2@ontario.cancer.ca

The Canadian Cancer Society Smokers’ Helpline Working with pregnant and post-partum women 7% of women age 20 to 44 years were pregnant or breast feeding at the time of their first contact with Smokers’ Helpline Quit Coaches operate from a perspective that is woman- centred rather than fetus-centred While we do not exclude concern for the fetus, the focus is on the woman’s health and goals. Use Motivational interviewing to support an identity shift from smoker to non-smoker Expanded proactive service offered, surrounding the due date Can receive up to 14 proactive calls from a Quit Coach