1 Treating Tobacco Use During Pregnancy Cecelia A. Gaffney, MEd Dartmouth Medical School May 16, 2005

2 Smoking Among Women Health Consequences Lung cancer is now the leading cause of cancer death among US women, surpassing breast cancer in About 90% of all lung cancer deaths among women who continue to smoke are attributable to smoking.

3 Smoking Among Women Health Consequences Each year during the 1990s, US women lost an estimated 2.1 million years of life due to smoking attributable deaths. Women who smoke also experience gender-specific health consequences, including increased risk of various adverse reproductive health outcomes.

4 Quitting Smoking during Pregnancy “Only 18-25% of all women quit smoking once they become pregnant.” “Only 18-25% of all women quit smoking once they become pregnant.” “Between 13 and 17% of pregnant women smoke in the United States.” “Between 13 and 17% of pregnant women smoke in the United States.” The Health Consequences of Smoking, A Report of the Surgeon General, 2004.

5 Call to Action Smoking is the most modifiable risk factor for poor birth outcomes Successful treatment of tobacco dependence can achieve: 20% reduction in low–birth-weight babies 20% reduction in low–birth-weight babies 17% decrease in preterm births 17% decrease in preterm births Average increase in birth weight of 28 g Average increase in birth weight of 28 g

6 Substance Use in Past Month Among Women Aged Years National Household Survey on Drug Abuse, % 2.4%2.7%

7 Tobacco Use in Pregnancy Maternal Harm Possible causal association - placenta previa -spontaneous abortion Probable causal association -ectopic pregnancy -preterm PROM Causal association -abruptio placenta

8 Tobacco Use in Pregnancy Infant Harm Causal association -abruptio placenta -small for gestational age -preterm delivery -Sudden Infant Death Syndrome (SIDS) -stillbirth

9 Effects of Maternal Smoking During & After Pregnancy “Compared with unexposed infants, babies exposed to secondhand smoke after birth are at twice the risk for SIDS, and infants whose mothers smoked before and after birth are at three to four times greater risk.” “Compared with unexposed infants, babies exposed to secondhand smoke after birth are at twice the risk for SIDS, and infants whose mothers smoked before and after birth are at three to four times greater risk.” The Health Consequences of Smoking, A Report of the Surgeon General, 2004.

10 Tobacco Exposure during Infancy and Early Childhood Causal association -otitis media -new and exacerbated cases of asthma -bronchitis and pneumonia - wheezing and lower respiratory illness

11 Cost of Complicated * Births *Complications include hemorrhage from placenta previa, maternal infection, fetal distress, malposition of the fetus CDC. MMWR 1997;46:1048–1050

12 Cost-effectiveness of Smoking Cessation Intervention JAMA 1997;278:1759–1766

13 More Missed Opportunities in Pregnancy National Ambulatory Medical Care Survey, 1995; Thorndike, et al, 1998 JAMA 279:604-8; 1991 JNCI 91:

14 Intervention Makes a Difference Smoking cessation intervention by clinicians improves quit rates Brief counseling works better than simple advice to quit Intervention works best for moderate (<20 cigarettes/day) smokers A woman is more likely to quit smoking during pregnancy than at any other time in her life

15 The Evidence-based Intervention for Smoking during Pregnancy Meta-analyses of randomized trials of smoking cessation interventions with pregnant smokers have concluded that: Meta-analyses of randomized trials of smoking cessation interventions with pregnant smokers have concluded that: A brief cessation counseling session of 5-15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials, significantly increases rates of cessation among pregnant smokers by 30 to 70 percent.

16 5 A’s Approach to Smoking Cessation 5 A’s Approach to Smoking Cessation AskAdviseAssessAssistArrange Adapted for pregnant women by ACOG Adapted for pregnant women by ACOG

17 Disclosure of Smoking Status Recent studies confirm non-disclosure Non-disclosure rates range from 3% to 13% Non-disclosure rates range from 3% to 13% Concerns with biomarkers Structured question still best method

18 Disclosure of Smoking Status Deception rates, as confirmed by comparing results of biochemical tests with self-reports, may be high among pregnant women, reaching 23% in some groups. Windsor 2000, Mullen 1991

19 Improving Disclosure Which of the following statements best describes your cigarette smoking? I have never smoked or have smoked fewer than 100 cigarettes in my lifetime I stopped smoking before I found out I was pregnant and am not smoking now I stopped smoking after I found out I was pregnant and am not smoking now I smoke some now but have cut down since I found out I am pregnant I smoke about the same amount now as I did before I found out I was pregnant Advise Congratulate patient

20 Spontaneous Quitters For the Woman Who Quits Prior to or Upon Learning of Pregnancy Reinforce her decision to quit Congratulate her on success in quitting Congratulate her on success in quitting Encourage her to stay quit Encourage her to stay quit

21 Smokers Not Ready to Quit 5 R’s (or motivational interviewing) 5 R’s (or motivational interviewing) Relevance Relevance Risks Risks Rewards Rewards Roadblocks Roadblocks Repitition Repitition

22 Disclosure of Pregnant Woman’s Exposure to SHS Since you found out you were pregnant, about how many hours a day, on average, are you in the same room with someone who smokes? Which of the following statements best describes the rules about smoking inside your home while you were pregnant? No one was allowed to smoke anywhere inside your home No one was allowed to smoke anywhere inside your home Smoking was allowed in some rooms or at some times Smoking was allowed in some rooms or at some times Smoking was permitted anywhere inside your home Smoking was permitted anywhere inside your home Source: Adapted from The Pregnancy Risk Assessment Monitoring System, The Centers for Disease Control and Prevention, 2002.

23 Disclosure of Child’s Exposure to SHS A validated, 5-part screening instrument for assessing child’s exposure has been developed and tested Does child’s mother currently smoke? Does child’s mother currently smoke? In the home? In the home? Does child’s father currently smoke? Does child’s father currently smoke? In the home? In the home? Is your child exposed to cigarette smoke on a regular basis (any exposure at least one time per week) from anyone other than the parents? Is your child exposed to cigarette smoke on a regular basis (any exposure at least one time per week) from anyone other than the parents? Source: Seifert JA, et al., 2002.

24 Treating Exposure to SHS Intervention trials have focused on parents of children with health problems Mixed results from trials Clinical settings in pediatric and group model HMO have shown some success Clinical settings in pediatric and group model HMO have shown some success More intensive interventions with biofeedback of child’s cotinine level have lead to significant reductions in exposure More intensive interventions with biofeedback of child’s cotinine level have lead to significant reductions in exposure Home based programs show mixed results Home based programs show mixed results

25 Treating Exposure to SHS Good evidence to support use of medicinal nicotine (MN) as a way to reduce exposure of children MN is least toxic way to get nicotine for both the smoker and those living or working with the smoker Complete substitution of MN for smoking is the goal

26 Treating Exposure to SHS If no cessation or use of MN, messages should be Don’t smoke in your home Don’t smoke in your home Don’t smoke in your car Don’t smoke in your car Stress impact of secondhand smoke exposure on immediate problem with child ear infections ear infections Bronchitis Bronchitis asthma asthma

27 Web Resources Smoke-Free Families: smokefreefamilies.org National Partnership: helppregnantsmokersquit.org