Helping Pregnant Women Quit

Smoking

Best Practice Interventions

Jolie PersonTexas Department of State Health Services

Participants will describe the adverse effects of

smoking on the mother, her unborn child, and family.

Participants will discuss the effectiveness of prenatal smoking cessation interventions.

Participants will compare three Best Practice interventions for smoking cessation.

Community Health Worker Continuing Education Unit: 1Competency: 0.5 Knowledge, 0.5 Communication

Learner Centered Objectives

Video Clip - 25 Ways to Quit Smoking. Bill Plimpton

Approximately 13% of women reported

smoking during the last 3 months of pregnancy.

Of women who smoked 3 months before pregnancy, 45% quit during pregnancy.

Among women who quit smoking during pregnancy, 50% relapsed within 6 months after delivery.

Prevalence of Tobacco Use

Pregnancy Risk Assessment Monitoring System (PRAMS)

A Smoking Partner A Large Number Of Children A High Rate Of Tobacco Consumption Deficiencies In Prenatal Care

Schneider, S., Huy C., Schutz J., & Diehl, K. (2010). Smoking cessation during pregnancy: a systematic literature review. Drug Alcohol Rev, 29.

Predictors of Smoking During Pregnancy

Tobacco is a plant whose brown-colored leaves

are cured and dried. Tobacco may also be classified as a drug.

By definition, a drug is a nonfood substance that can cause changes in the function of the body and/or mind.

Tobacco 101

Types of Tobacco

There are over 4,000 chemicals in tobacco

smoke

599 Additives

At least 69 of those 4,000 chemicals are

known to cause cancer

Cancer-Causing ChemicalsFormaldehyde: Used to embalm dead bodiesBenzene: Found in gasolinePolonium 210: Radioactive and very toxicVinyl chloride: Used to make pipes

Toxic MetalsChromium: Used to make steelArsenic: Used in pesticidesLead: Once used in paintCadmium: Used to make batteries

Poison GasesCarbon monoxide: Found in car exhaustsHydrogen cyanide: Used in chemical weaponsAmmonia: Used in household cleanersButane: Used in lighter fluidToluene: Found in paint thinners 

Secondhand Smoke

Mainstream Smoke

(smokers inhale about 15% of the

smoke from a cigarette)

Sidestream Smoke(smoke from the

burning end of the cigarette)

Responsible for 3,000 lung cancer deaths in non-smokers each year

(Source: American Cancer Society)

Not a safe substitute for cigarettes Increases the risk for oral cancer and other

health problems Contains nicotine, the same addictive drug

found in cigarettes.

Smokeless Tobacco

Adverse Effects of Tobacco

Use Frequent colds Smoker’s Cough Gastric Ulcers Chronic Bronchitis Increase in heart rate

and blood pressure Hardening of the

arteries Gum disease, recession

Emphysema Heart Disease Stroke Cancer Premature aging Delayed wound

healing Risk of developing

Type 2 diabetes is 2-3x higher

Adverse Effects of Tobacco

Use

Video Clip - Smaller babieshttp://www.youtube.com/watch?v=ypn3xpvA1eQ&feature=related

Difficulty getting pregnant Placenta separates from the womb too early,

causing bleeding Placenta covers the cervix, causing complications Water breaks too early

More studies needed: Possible adverse effect may include pregnancy occurring outside of the womb

Centers for Disease Control

Adverse Effects of Tobacco Use

…on mom

Children suffer from bronchitis, pneumonia, hyperactivity, middle ear infections, upper respiratory infections and are frequently hospitalized.

Adverse Effects of Tobacco Use

…on family members

Teens are more likely to become smokers when a parent smokes. As a result, they will suffer greater long-term health effects such as cancer, heart disease and progressive lung disease like emphysema.

Of particular concern are carbon monoxide, nicotine and oxidizing chemicals.Nicotine may cause constrictions in the blood vessels of the umbilical cord, thereby decreasing the amount of oxygen available to the fetus. This increases the risk of complications such as: Miscarriage Premature birth Stillbirth Spontaneous abortion

Adverse Effects of Tobacco Use

…on the unborn baby

Babies born to mothers who smoke during pregnancy have an increased risk of:

Sudden Infant Death Syndrome (SIDS) Lower birth weight Mental retardation Brain dysfunction Respiratory infections

Adverse Effects of Tobacco Use

…on the newborn

No matter what their age, most smokers want

to quit and most attempt to quit every year.

Among current smokers, 70% report they want to quit completely.

Facts about Quitting Smoking

a. Clinical Interventionsb. Five A’sc. Brief Motivational Interviewingd. Pharmacotherapye. Quit Line / Telephone Counseling

Interventions

Recommendation: All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis.

Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A)

Clinical Interventions

Recommendation: All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A)

Clinical Interventions

Recommendation: Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A)

Recommendation: There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. (Strength of Evidence = A)

Recommendation: Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use. (Strength of Evidence = A)

Clinical Interventions

1.ASK the patient about smoking status at the first prenatal visit and follow-up with her at subsequent visits.a) I have NEVER smoked or have smoked < 100 cigarettes in my

lifetimeb) I stopped smoking BEFORE I found out I was pregnant…c) I stopped smoking AFTER I found out I was pregnant…d) I smoke some now, but I have cut down…e) I smoke regularly now, about the same as before…

If a-c, Reinforce her decision to quit (or never start), congratulate her on quitting, encourage her to remain smoke free.If d-e, Document smoking status and proceed to next four A’s.

Five A’s

2.ADVISE the patient who smokes to stop by providing advice to quit with information about the risks of continued smoking to the woman, fetus, and newborn.

3.ASSESS the patient’s willingness to attempt to quit smoking at the time. Quitting advice, assessment, and motivational assistance should be offered at subsequent prenatal care visits.

Five A’s

4.ASSIST the patient who is interested in quitting by providing pregnancy-specific, self-help smoking cessation materials. Support the importance of having smoke free space at home and seeking out a “quitting buddy,” such as a former smoker or nonsmoker. Encourage the patient to talk about the process of quitting. Offer a direct referral to the smoker’s quit line (1-800-QUIT NOW) to provide ongoing counseling and support.

Five A’s

5.ARRANGE follow-up visits to track the progress of the patient’s attempt to quit smoking. For current and former smokers, smoking status should be monitored and recorded throughout pregnancy, providing opportunities to congratulate and support success, reinforce steps taken towards quitting and advise those still considering a cessation attempt.

Modified from Treating Tobacco Use And Dependence: 2008 update. Clinical Practice Guideline. www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

Five A’s

Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future. (Strength of Evidence = B)Motivational interviewing is a technique whereby clinicians focus on the patient’s desire to quit smoking, by developing an awareness of the discordance between knowledge and behavior, and then supporting patient’s self-efficacy in achieving that desire.There are 4 principles of motivational interviewing: Express empathy, Develop discrepancy, Roll with resistance, and Support self-efficacy.

Brief Motivational Interviewing

Nicotine Replacement Products Patch Gum Inhaler Nasal Spray LozengePharmaceuticals Bupropion (Zyban)

PharmacotherapyInsufficient evidence of effectiveness

“The use of nicotine replacement products or other pharmaceuticals for smoking cessation aids during pregnancy and lactation have not been sufficiently evaluated to determine their efficacy or safety.” U.S. Preventive Services Task Force, 2009

Pharmacotherapy

“Pregnant smokers should be encouraged to attempt cessation using educational and behavioral interventions before using pharmacological approaches. Treatment with nicotine replacement therapy during pregnancy requires that the mother be well informed about the potential risks vs. benefits.” Benowitz, Dempsey Nicotine & Tobacco Research, February 2003

Pharmacotherapy

“The use of nicotine replacement therapy should be undertaken with close supervision and after careful consideration and discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy.”The American College of Obstetricians and Gynecologists, 2010

Pharmacotherapy

Recommendation: Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. (Strength of Evidence = A)Quit lines offer information, direct support, and ongoing counseling, and have been very successful in helping pregnant smokers quit and remain smoke free.

1-800-QUIT NOW

Quit Line / Telephone Counseling

Best Practice

Tips for Quitting

http://www.youtube.com/watch?v=yWTRiI8NsQA&feature=related

http://www.youtube.com/watch?v=lf01Ti6bH8U

If you smoke when you: Try doing this:

Drink coffee Have hot chocolate or herbal tea 

Finish a meal Get right up, take a walk, or go into another room 

Watch TVDo something else with your hands(start a craft) and mouth (chew gum, eat a hard candy)

Need to relax Take a nonsmoking break or walk,or take a break take a bubble bath, call a friend,do your nails, ask a friend to babysit for 30 minutes, even if you stay home

Tips for Quitting

Tips for Quitting

Your hands: Your mouth:Knit or sew Chew gum

Play with a rubber band Eat some fresh fruit

Hold a pen or pencil Use a straw or toothpick

Draw or doodle Suck on hard candy

Squeeze a soft rubber ball Try a cinnamon stick

Work on a craft project Sip water or juice

Decorate your baby’s room Have a frozen fruit bar

Massage your fingers or hands Have some popcorn

 It also helps to keep your hands and mouth busy.

www.dshs.state.tx.us/tobaccoResources

BecomeAnEX.org

Great tools to help people quit

Online Quit Plan

Resources

www.cdc.gov/tobacco

Resources

Smokefree.gov or espanol.smokefree.govResources

Information for Smokers and Their Families1-800-QUIT-NOW -- (1-800-784-8669); TTY 1-800-332-8615. Provides support in quitting, including free quit coaching, a free quit plan, free educational materials, and referrals to local resources.Smokefree Women -- Provides information and resources on quitting smoking targeted at pregnant and non-pregnant women.Smokefree.gov -- Provides general resources for smokers to quitBecome an EX: For pregnant and postpartum smokers -- A quit smoking program developed by the American Legacy Foundation.Stay Away from Tobacco -- Smoking cessation resources for patients and providers.The March of Dimes -- Quitting tips for pregnant smokers.Smoke-free homes and cars program -- Provides materials and resources for protecting children from secondhand smoke developed by the Environmental Protection Agency..

Resources

Information for Health Care ProfessionalsAmerican College of Obstetricians and Gynecologists: Smoking Cessation -- Smoking cessation resources for patients and providersCenters for Disease Control and Prevention, Division of Reproductive Health -- Highlight of data on tobacco use during pregnancy and resources.Office of the Surgeon General: Tobacco Cessation Guideline Clinical Practice Guidelines, Treating Tobacco Use and Dependence, is available here. The guideline was designed to assist clinicians; smoking cessation specialists; and health care administrators, insurers, and purchasers in identifying and assessing tobacco users and in delivering effective tobacco dependence interventions. This site also has clinician resources such as a Quick Reference Guide, tear sheets for primary and prenatal care providers, and consumer materials.

Quick Reference Guide for Clinicians. Treating Tobacco Use and Dependence. (PDF) --This reference guide contains strategies and recommendations from the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence. (requires Adobe Reader)

Information for Health Care ProfessionalsSmoke-Free Families -- Resources to help counselors of pregnant women who smoke, includes clinician resources, technical assistance tools, and patient materials.The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program -- An evidence-based program that can be implemented in offices to help pregnant women quit smoking.Treatobacco.net -- Presents evidence-based information about the treatment of tobacco dependence.

Information for Health Care ProfessionalsAmerican Academy of Pediatrics (AAP) -- Provides tools and resources to help clinicians and communities, and supports research and policy development to create a healthy environment for children, adolescents, and families. Also includes the AAP Policy Statement of tobacco use as a pediatric disease. How Tobacco Smoke Causes Disease: What It Means to You -- An easy-to-read booklet explaining new scientific findings about how deadly cigarettes are and how quickly they can damage your body. Infant Risk Center -- Provides up-to-date evidence-based information on the use of medications during pregnancy and breastfeeding.

Question and document tobacco use at every

visit. Understand the challenge to quit and expect

relapse. Identify readiness to quit to best tailor

approach to patient. Treatment is effective and multiple options

allow for individualized interventions.

Key Messages for Promoting Smoking Cessation

Jolie PersonMaternal and Child Health ProgramTexas Department of State Health ServicesHealth Service Region 1 - Canyon, Texasjolie.person@dshs.state.tx.us806-655-7151

Thank you!