Effective Evidence Based Interventions

To Help Women Quit Smoking

Julie Daniels DNP, CNM, CTTS

Objectives• 1. Identify at least three dangers of tobacco exposure

during the prenatal period.• 2. Identify at least two key components of evidence based

smoking cessation treatment geared to pregnant women and who should be screened for tobacco use.

• 3. Identify at least two of the three key components of Motivational Interviewing.

• 4. Identify at least one way nicotine and one way carbon monoxide cause harm to the developing fetus.

• 5. Identify at least two medications utilized for tobacco dependence and when they might be considered for a pregnant client.

Introduction• Overwhelming evidence that maternal smoking causes

adverse effects on maternal, fetal and infant health• Nationally 17.3% of women smoke pre-pregnancy and 15%

during pregnancy (Tong et al., 2013)• Providing support and effective treatment can double quit

rates• US Public Health Service advises screening and treatment of

all pregnant women (Fiore’ et al., 2008)• Smoking cessation a Healthy People 2010 objective• Effective training is available at little or no cost

What’s in a cigarette?

Both CO and Oxidizers contribute to risk of thrombosis

Over 4000 ingredients besides Tobacco

60 Carcinogens (CDC, 2003) Carbon Monoxide Binds to Hgb at 200x

strength of Oxygen, causes chronic hypoxia (Dempsey & Benowitz, 2004)

Oxidizing Chemicals lead to vasoconstriction and affect collagen synthesis

Dangers to pregnancy• Primary and Secondary Infertility• Increased risk for Spontaneous Abortion• Increased risk for Ectopic Pregnancy• Increased risk placenta previa• 2x risk of Placental Abruption (10-25% mortality)• Pre-Term Birth (early PTB more associated)• Pre-Term Premature Rupture of Membranes• Increased rates of Stillbirth• Fetal Growth Restriction• (Cnattingus, 2004)

Dangers to infant

• Increased risk Neonatal Mortality (1st 4wk)• Sudden Infant Death Syndrome (2-3x risk)• Oral Clefts (Cnattingus, 2004)• Asthma• Pneumonia • Bronchitis• Middle Ear Infections• (www.epa.gov/smokefree/healtheffects.html)

Behavioral effects

• Attention Deficit Disorder

• Aggressive behavior

• Toddler Negativity (4x Risk)

• Decreased Academic Achievement

• (Brook, JS. (2000); Brook, DW.(2008), Batsatra, (2003))

Why its harder for pregnant women• Nicotine metabolism (Ebert, van der Riet & Fahy, 2009)

• Social pressures

• Depression (2x risk of being a “non-quitter”)(Linares Scott, Heil,

Higgins & Badger, 2009)

• Low education

• Lower SES

Smoking cessation timeline –health benefits over time (ACS)

In 20 minutes, your blood pressure and pulse rate decrease, and the body temperature of your hands and feet increase.

Carbon monoxide in cigarette smoke reduces the blood’s ability to carry oxygen. At 8 hours, the carbon monoxide level in your blood decreases to normal. With the decrease in carbon monoxide, your blood oxygen level increases to normal.

At 24 hours, your risk of having a heart attack decreases. At 48 hours, nerve endings start to regrow and the ability to smell and taste is enhanced. Between 2 weeks and 3 months, your circulation improves, walking becomes easier and you don’t cough or

wheeze as often. Phlegm production decreases. Within several months, you have significant improvement in lung function.

In 1 to 9 months, coughs, sinus congestion, fatigue and shortness of breath decrease as you continue to see significant improvement in lung function. Cilia, tiny hair-like structures that move mucus out of the lungs, regain normal function.

In 1 year, risk of coronary heart disease and heart attack is reduced to half that of a smoker. Between 5 and 15 years after quitting, your risk of having a stroke returns to that of a non-smoker. In 10 years, your risk of lung cancer drops. Additionally, your risk of cancer of the mouth, throat,

esophagus, bladder, kidney and pancreas decrease. Even after a decade of not smoking however, your risk of lung cancer remains higher than in people who have never smoked. Your risk of ulcer also decreases.

In 15 years, your risk of coronary heart disease and heart attack in similar to that of people who have never smoked. The risk of death returns to nearly the level of a non-smoker.

Evidence based intervention

• “5A’s” or “Brief Intervention” (Fiore et al., 2008)

• Patient-centered activities such as listening to patients, considering their priorities, developing collaborative goals and eliciting coping suggestions that are congruent with patient values, preferences and social environment are at the heart of the 5As approach. (Glasgow, Emont & Miller, 2006)

SCREENING

• How to ASK – multiple choice

• ALL patients EVERY visit

• Follow up and document

5 A’s

ASKADVISE

ASSESSASSIST

ARRANGE

advise

Motivational Interviewing

Client-Centered

Motivational interviewing• ASK permission / Respect for client & their Journey• “Equal footing” or “Meeting of experts” the patient is

expert in who they are • Safe place to voice concerns / NO judgment• ASK about their understanding of smoking and its effects• Roll with resistance has now become Dance don’t wrestle• Reflect “OK, it sounds like you have been smoking about

15-20 cigarettes a day for about 5 years, does that sound about right?” Use ranges.

• ASK “Can I give you information to address your concern?”• Listen & Elicit “Tell me your thoughts about quitting

smoking.”

Motivational interviewing• Explore options for change: “what do you think you will

do?” or “If you were to quit what do you see as obstacles?”• Form a Plan of Action: “How would you plan for quitting?”

“How would you deal with _________ (named obstacle)?”• Close on Good terms: Summarize, Encourage & What

agreement was reached (review) [SEW]• Common tool: Confidence Scale 0-----------5----------10

“How confident are you that you about quitting?” “Why not lower?” “What could move you to ____ (higher)?”

• Purpose of MI: Stimulate motivation, listen & understand, summarize points

Take away• Smoking is a modifiable risk factor for adverse outcomes• Smoking cessation Interventions are effective • Pregnancy is the most likely time for a woman to quit in her

lifetime• Quitting smoking is the most important thing any smoker

can do to improve their health in their lifetime• Motivational Interviewing is a great tool to assist patients to

make positive changes in their health• 5A’s work! And can easily be added to your clinical setting• Resources are available to help you and your clients

Educational Resources• ACOG Virtual Clinic for Smoking Cessation $25• ACOG Smoking Cessation During Pregnancy 2011 Self-

Instructional Guide and Toolkit FREE• Thedoctorschannel.com offers MI CME with 10 videos and

post tests FREE• www.sbirtonline.org MI webinar by Alan Lyme of SAMSA

FREE webinar, $10 for CEU• The Smoking Cessation Leadership Center• http://smokingcessationleadership.ucsf.edu/• Tobacco Free Nurses• www.tobaccofreenurses.org/

Patient resources• www.becomeanex.org (online program)• www.lungusa.org (online program)• www.women.smokefree.gov• www.smokeclinic.com• www.ceasesmoking2day.com• www.cdc.gov/tobacco/how2quit.htm• www.quitnet.com (online program)• www.smokefree.gov (online program)• www.nicotine-anonymous.org (12 step model)(online

program)

For the C Generation

• Text2quit.com (29.99 for 4 months) [Facebook & Twitter]

• Smokefree.gov SmokefreeTXT program(free)• Quit for life: texts, emails, support & info.

[ACS](free)• Drugfree.org Smartphone App. (free)

What Works for Non-Pregnant• Counseling and Medication Combinations - Quit Rate 26-32%• Medication Combinations - Quit Rate 26-36%• Varenicline (Chantix) - Quit Rate 33%• Nicotine Replacement Therapy - Quit Rate 19-26%• Bupropion SR (Zyban) - Quit Rate 24%• Counseling - Quit Rate13-17% [1-800-QUIT NOW]• Self-Help - Quit Rate 9-12%• Fiore’ et al., 2008 and

http://www.surgeongeneral.gov/tobacco/• For more information on other resources to help patients quit:

Smoking Cessation Leadership Center provider resources page or download the SCLC Catalogue of Tools (PDF).

References 1Abatemarco, D.J., Steinberg, M.B., & Delnevo, C.D. (2007). Midwives’ knowledge, perceptions, Beliefs, and practice supports regarding tobacco dependence treatment. Journal of Midwifery & Women’s Health, 52, 451-457.Batstra, L., Hadders-Algra, M., & Neeleman, J. (2003). Effect of antenatal

exposure to maternal Smoking on behavioral problems and academic achievement in children: Prospective evidence from a Dutch birth cohort. Early Human Development, 75, 21-33.

Benowitz, N., & Dempsey, D. (2004). Pharmacotherapy for smoking cessation during pregnancy. Nicotine & Tobacco Research, 6 [Supp. 2], S189-S202.Brook, J. S., Brook, D.W., & Whiteman, M. (2000). The influence of maternal smoking during pregnancy on the toddler’s negativity. Archives of Pediatrics and Adolescent Medicine, 154, 381-385.

References 2Brook, J.S., Duan, T., Zhang, C., Cohen, P.R., & Brook, D.W. (2008). The association between attention deficit hyperactivity disorder in adolescence and smoking in adulthood. American Journal on Addictions, 17(1), 54-59.CDC Reproductive Health. (2011). Tobacco use and pregnancy: Home. Retrieved from http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/

Cnattingius, S. (2004). The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy

outcomes. [Supplement 2] Nicotine and Tobacco Research, 6, S125-S140.Dempsey, D.A., & Benowitz, N.L. (2001). Risks and benefits of nicotine to

aid smoking cessation in pregnancy. Drug Safety, 24 (4), 277-322.

References 3Ebert, L., van der Riet, P., & Fahy, K. (2009). What do midwives

need to understand / know about smoking in pregnancy? Women and Birth, 22, 35-40.Fiore’, M.C., Ja’en, C.R., Baker, T.B., Bailey, W.C., Benowitz, N.L.,

Curry, S.J.,…Dorfman, S.F. (2008). Treating tobacco use and dependence: 2008 Update. Clinical Practice

Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service.Glasgow, R.E., Emont, S., & Miller, D.C. (2006). Assessing the 5

A’s for patient-centered counseling: alternatives and future directions. Health Promotion International, 21 (3), 2245-2255.

Linares Scott, T., Heil, S.H., Higgins, S.T., & Badger, G.J. (2009). Depressive symptoms predict smoking status among pregnant women. Addictive Behaviors 34(8), 705-708.

References 4Lumley, J., Chamberlain, C., Dowswell, T., Oliver, S., Oakley, L., & Watson, L. (2009).

Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews, 3. doi: 10.1002/14651858.CD001055.pub3

Price, J.H., Mohamed, I., & Jeffery, J.D. (2008). Tobacco intervention training in American College of Nurse-Midwives accredited education programs. Journal of Midwifery & Women’s Health, 53(1), 68-74.

Tong, V.T., Dietz, P., Farr, S., D’Angelo, D., & England, L. (2013). Estimates of smoking before and during pregnancy, and smoking cessation during pregnancy: Comparing two population-based data sources. Public Health Reports, 128, 179-188.