Tobacco Use in Pregnancy: Effects and Intervention

Beth Bailey, PhDAssociate Professor of Family Medicine

Director, Division of ResearchEast Tennessee State University

Overview» Effects of pregnancy smoking on exposed children

» Extent of the problem in rural Appalachia

» Intervention efforts

» Intervention effectiveness

» Current efforts & resources

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Effects of Pregnancy Smoking

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Gestation Infancy Childhood Adolescence Adulthood

SEEN DURING:

NEGATIVELY AFFECTS:

Gestational Development

Infant Morbidity

and Mortality

Physical Health

Psychological HealthGrowth

Behavior

Emotional Regulation

Attention

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» Data from both animal (experimental) and human (controlled correlational) studies

» Miscarriage and stillbirth – more than 2x risk» Preterm delivery (1+week early)» Fetal growth restriction and consequent low birth

weight (300+g reduction)

Effects of Pregnancy Smoking

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Effects of Pregnancy Smoking

Premature Baby Healthy Baby$41,610 $2,766

Health Care Costs During the First Year of Life

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˃ An inch or more shorter than peers at age 2; but increased risk of obesity

˃ Twofold increased risk for SIDS

˃ Substantially increased rates of asthma,

allergies, respiratory and ear infections (50% to 300% increased risk)

Effects of Pregnancy SmokingGrowth deficits and health problems into childhood

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Most recent surveillance data» The following are attributable to PREGNANCY smoking:˃ 5.3% - 7.7% of preterm deliveries

˃ 13.1% - 19.0% of low birth weight deliveries

˃ 5.2% of all infant deaths (13% for Native Americans)

» Effects are dose dependent» If pregnant smokers were to halt tobacco use, over

$300 million in health care costs, and 986 infant deaths would be averted annually in the U.S.

Effects of Pregnancy Smoking

Dietz, et al, 2010Salihu, et al, 2003

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Most recent surveillance data» SIDS is the leading “cause” of infant death» Children exposed to smoking prenatally have a 2.7

times increased risk of SIDS» 23.2% - 33.6% of SIDS deaths can be attributed to

PRENATAL cigarette exposure» Each 10% increase in the price of cigarettes reduces

the average number of SIDS deaths by 6.9% - 7.6%

Effects of Pregnancy Smoking

Dietz, et al, 2010Markowitz, 2008

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» Increased risk of impulsivity, hyperactivity, inattention» Delays in learning, memory, and language

development» Poor academic achievement» Behavior problems including aggression and

delinquency; increased risk of substance use/abuse

Effects of Pregnancy SmokingLong-term developmental problems

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» Marijuana is the most commonly used illicit drug during pregnancy

» Prenatal marijuana exposure has not been found to impact fetal and infant morbidity and mortality to the degree of prenatal cigarette exposure

Effects of Pregnancy SmokingWhat about marijuana?

» High rates of polydrug use complicate studies» Marijuana has either not been found to significantly impact

birth weight, or to affect it by less than 100gm» Use is unrelated to fetal or infant death, preterm delivery, or

physical abnormalities» A few studies have shown long term developmental effects

of prenatal marijuana exposureBrown & Graves, 2013

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Effects of Pregnancy SmokingIn NE TN, looked at immediate outcomes related to pregnancy smoking – all births in 2 yrs at 2 regional hospitals (N=4144)

Bailey BA, Jones Cole LK. Rurality and birth outcomes: Findings from Southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health, 25(2), 141-149, 2009.

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Effects of Pregnancy SmokingProspective study at one prenatal practice looked at smoking compared to other biochemically verified substance use (N=221)

Clearly, smoking was the strongest predictor of birth weight/LBWRates of pregnancy smoking were 4 times the national rate of 12%Bailey B, Byrom A. Factors predicting birth weight in a low-risk sample: The role of modifiable pregnancy health behaviors. Maternal Child Health Journal, 11, 173-179, 2007.

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A Few Final Notes About Pregnancy Smoking» Amount and timing of exposure are important » No real threshold: Effects with as few as 2 cigarettes

per day, but greatest effects at a half a pack/day +» Early pregnancy exposure linked to subtle

developmental effects, but late exposure more detrimental to growth and health in particular

» So, quitting smoking or even cutting down by 3rd trimester may lead to significant health benefits

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A Few Final Notes About Pregnancy Smoking

» Second Hand Smoke is smoke that smokers breathe out and the smoke that comes from burning cigarette

» Third Hand Smoke is smoke contamination that remains in the air and on surfaces after cigarette is extinguished

» BOTH of these are harmful to the developing fetus and developing child – causing effects much like what are seen due to primary prenatal exposure

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Smoking vs Other Substance Use» Cessation of alcohol and illicit drug use is often

prioritized over addressing smoking» This is misguided for several reasons:

˃ In most regions, rates of cigarette smoking during pregnancy are double or triple the rates of other substance use – impacting more pregnancies

˃ Most research has shown tobacco exposure (since daily and often continuous) is just as harmful, and in some ways MORE harmful than other substance use, especially compared to light to moderate drinking, and non-daily use of marijuana and harder drugs

˃ Ex: One of the few comparative studies done showed that of tobacco, alcohol, cocaine, and marijuana, only pregnancy tobacco (-400gm) and alcohol (-200+gm) use during pregnancy significantly impacted birth weight ; effects greater for older women [Janisse, Bailey, Ager, Sokol. Alcohol, tobacco, cocaine and marijuana use: Relative contributions to preterm delivery and fetal growth restriction. Substance Abuse, 2014.]

» Pregnant women should be encouraged and assisted to eliminate the use of ALL substances during pregnancy

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Extent of the Problem

U.S. TN Appal TN0

5

10

15

20

25

30

35Pe

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tage

of P

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25% 28% 30-42%<10%<10% Rates increased from 2006-2007

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Extent of the Problem» Pregnancy smoking is not limited to certain “types”

of women» However, there are some predictive

sociodemographic factors:˃ Less education˃ Lower income/lack of resources˃ Caucasian˃ Rural residence˃ Use of other substances˃ Social risks including IPV, lack of social support

» Women with fewer risk factors are twice as likely to deny use

Bailey BA, Wright HN. Assessment of pregnancy cigarette smoking and factors that predict denial. American Journal of Health Behavior, 34(2), 166-176, 2010.

Bailey BA, Jones Cole LK. Rurality and birth outcomes: Findings from Southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health, 25(2), 141-149, 2009.

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Extent of the Problem» 208 Appalachian counties in TN, VA, WV, KY, NC:

˃ 73% are health professional shortage areas˃ 20% have no hospital; 50% have only 1˃ 65% do not have obstetric or delivery services˃ 70% do not have substance abuse services˃ 54% of residents must drive at least 30 miles for health care services;

26% drive 60 miles or more

» Recent report by the March of Dimes detailed factors influencing the preterm birth rates in each state – in TN, WV, VA, KY, NC:˃ Smoking (25%+; SHS)˃ Inadequate health care access

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Extent of the Problem» Prenatal Care Provider Survey» Sent out a survey to the 46 obstetricians

in the 6 county area of NE TN» Survey adapted from one used in OH» Asked about pregnancy smoking

practices and beliefs, and adherence to ACOG recommendations - 5A’s: ˃ Ask – inquire at every visit with multiple response choice Q˃ Advise – clear, strong, personalized advice to quit˃ Assess – determine willingness to make a quit attempt˃ Assist – provide tips and suggestions for successful quitting˃ Arrange – for follow-up and other assistance

» Surveys were returned by 30 physicians (65%)

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Extent of the Problem

Always

UsuallySometimes

Seldom

Never

ASKHow often do you inquire

about smoking status during prenatal visits?

27%

ADVISEHow often do you give

clear, strong advice to quit to pregnant smokers?

63%

ASSESSHow often do you assess

whether a pregnant smoker is willing to make a quit attempt?

20%

ASSISTHow often do you assist pregnant patients by

encouraging the use of problem solving skills for smoking

cessation?

17% 24%

How often do you use counseling to help

pregnant smokers quit?

ARRANGEHow often do you arrange

for other assistance?

3%

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Extent of the Problem» Only 50% of respondents felt there

was SIGNIFICANT VALUE in spending time during the clinical encounter addressing smoking

» Only 40% were VERY CONFIDENT in their ability to recommend behavior change related to smoking

» Only 53% felt that recommending behavior change was likely to be effective

» Only 43% believed that pregnancy smoking could lead to SIGNIFICANT fetal effects

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Extent of the Problem» Reasons for not using the 5 A’s included lack

of time, not believing that efforts would produce behavior change, belief that is was more important to address other health behaviors including other substance use, and not knowing where to send patients for additional cessation assistance

» Clearly, obstetric providers in NE TN fall well short of ACOG recommendations for universal inquiry about smoking and brief intervention assistance in prenatal care

» This is particularly concerning given the high rates of pregnancy smoking and the known harmful short and long term effects

Bailey BA, Jones Cole L. Are obstetricians following best-practice guidelines for addressing pregnancy smoking? Results from Northeast Tennessee. Southern Medical Journal, 102(9), 894-899, 2009.

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The Intervention» In January of 2007, the Tennessee

Governor’s office strengthened efforts to improve birth outcomes in the region and funded the Tennessee Intervention for Pregnant Smokers (TIPS) program for four years; refunded through end of 2012

» TIPS was a multi-faceted approach that aimed to reduce pregnancy smoking rates and improve birth outcomes in 6 counties of NE TN

www.etsu.edu/tips

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The InterventionThe TIPS program involved:

1) Physician training in providing smoking cessation counseling as a routine part of prenatal care

2) Nurse training in providing smoking cessation counseling as part of inpatient & outpatient services

3) Provision of prenatal counseling and case management services in high risk practices

4) Provision of a hospital-based counselor/case manager for admitted high-risk women and those post-partum

5) Education/training programs for nursing, public health, respiratory therapy, medical students; interdisciplinary community work

6) Community-based education and cessation workshops7) Work with county health departments to integrate smoking screening

and intervention8) Development of self-help materials

5 FT staff, 4 PT staff; 4 FTE+ in students each term

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The Intervention» All TIPS services were available to

prenatal patients in NE TN who were:˃ Current smokers˃ Exposed to significant SHS˃ Former smokers < 2 years smoke-free

» Trained prenatal care providers offered: ˃ Brief smoking cessation assistance: 5 A’s˃ Referrals to TIPS Case Managers

» Substantial research component –interviews during pregnancy & post-partum to evaluate program

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The InterventionCounseling/Case Mgmt Services:» Bachelors level health educators trained in

smoking cessation counseling» 3 FT – 2 dedicated to largest/highest risk

practices; 1 floater/on call to others» Provided expanded 5 A’s counseling with self-help

materials » Provided support for reduction of life stressors

including IPV» Assisted with finding other resources, referrals to

other needed services (especially mental health), and family smoking cessation

» Goal: Cessation or significant reduction by 26 wks

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The Intervention» Over 3000 pregnant smokers received

scheduled case manager services; 8000+ received care from trained providers

» 1063 women (including non-smoker controls) participated in the research; maintained over 750 to 6 mo PP

» Developmental assessment: 226 15-month-olds» Also a historical smoker cohort (N=461) for

comparison on intervention outcomes (all smokers from participating practices for the 12 months prior to program start up)

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The InterventionMost Utilized Intervention Components

Component/Service Use

Second hand smoke information and assistance 78%

Program-designed self-help book 57%

Relapse prevention information and assistance 41%

Referral to the state Quitline 38%

Assistance and information for family members 34%

Practical assistance (food, housing, transportation, government services) 31%

Counseling/assistance/information about stress relief 17%

Counseling/referral for mental health issues 17%

Assistance related to intimate partner violence 2%

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Intervention SuccessAll Intervention Patients

Quit Smoking Completely

Significantly Reduced Smok-ingContinued Smok-ing at Same Rate

42% had at least one quit attempt

28%23%

49%

Control Group Patients

Quit Smoking CompletelySignificantly Reduced Smok-ingContinued Smoking at Same Rate

10%65%

25%

A recent meta-analysis of pregnancy smoking cessation interventions revealed a 15.1% quit rate by delivery for interventions comparable to or more intense than the TIPS equivalent of 4 or more Case Manager sessions (Lumley et al., 2008).

Even among those who did not quit, average amount of smoking reduced from 17.7

cig/day to 8.6 cig/day

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Intervention SuccessBirth Outcome Intervention

Group(n=1486)

Control Group

(n=461)p

Birth Weight (gm) 3063 2793 <.001

LBW (%) 13.6% 24.9% <.001

Birth Length (in) 19.4 18.8 <.001

Gestational Age (wks) 38.6 38.6 .940

Apgar score – 1 min 7.7 7.7 .718

Apgar score – 5 min 8.8 8.6 .002

NICU Admission (%) 7.6% 19.5% <.001

Neonatal/fetal demise .8% 2.6% <.001

Prenatal care utilization (%< Adeq) 27.4% 41.6% <.001

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Intervention Success

• All differences (except head circumference) between smokers and those who quit by 26 wks significant at p<.05

• All associations remained significant after control for background factors

Outcomes at 15 months Smoker thru pregnancy

Quit by 26 wks

Growth PercentilesHeight 48.9 54.1

Head circumference 47.4 54.2

Weight 61.3 52.6

Health History5+ non-well child visits 57.1% 37.1%Dx Allergies 31.3% 16.9%Dx Asthma 15.5% 14.3%

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Intervention Success

2006 2007 2008 2009 2010 2011 20120

5

10

15

20

25

30

35 Since the beginning of the TIPS project

in mid-2007, pregnancy smoking rates in the region

have decreased 28%

• Also during that time, preterm birth rates have dropped 25%, and low birth weight rates have dropped 19%.

• As comparison, statewide in Tennessee, pregnancy smoking rate in 2012 was 17.0%, an 11% decrease since 2006

Perc

enta

ge

30.9 31.2

26.9 26.8 26.424.8

22.4

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Intervention Success» In 2012, follow up to 2007 physician survey to look at the effects of

TIPS provider trainings/community educational activities» All 46 obstetrics providers in the six-county area again received

surveys; returned by 65% (n=30)» Knowledge of the harmful effects of pregnancy smoking increased

substantially in all areas» Knowledge of how to use the 5 A’s also increased significantly» However, providers were no more likely to intervene with pregnant

smokers or use the 5 A’s specifically» They also did not indicate any increase in their confidence to

successfully intervene with pregnant smokers; still indicated lack of time as the biggest barrier

» A model where busy obstetricians receive training and support to intervene with pregnant smokers may not produce meaningful changes in care or reductions in pregnancy smoking

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Intervention Success» Part of TIPS program included integrating education about pregnancy

smoking and intervention into the nursing curriculum at ETSU» Third year nursing students beginning obstetric/ pediatric/ psychiatric

clinicals attend a 1.5 hour training on harmful effects and using 5 A’s» Trainings conducted each semester since 2009; data for 7 semesters,

649 nurses so far» Pre-test, post-test, and 4 month follow-up surveys assessed

knowledge, attitude, and comfort with addressing pregnancy smoking

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Intervention Success» Knowledge scores increased from pre-test (62% correct) to post-test (81%;

t=24.9, p<.001), with gains retained at 4 month follow-up (82%)» At 4 month follow-up, most students reported addressing smoking with

multiple pregnant patients during clinicals (94%), half felt the patients benefitted from their actions; 58% confident in their intervention skills

» The vast majority of participants reported the training had been beneficial (83%), and indicated their commitment to addressing smoking with pregnant patients once they graduated (90%)

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Intervention Success» Training can increase nursing student knowledge, skill, comfort, and

willingness to address smoking with pregnant women» However, it appears ongoing education may be needed to promote

skills and confidence long term» In rural Appalachia, where smoking rates are high and provider efforts

to address pregnancy smoking are at best inconsistent, educating current nursing students could have substantial impact on pregnancy smoking rates and birth outcomes into the future

Bailey B, McGrady L, McCook J, Greenwell A. Educating nursing students on pregnancy smoking issues to improve regional intervention efforts. Presented at the annual meeting of AWHONN, June 2013, Nashville, TN.

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Intervention Success» Cost Benefit Ratio – was the TIPS Program money well spent?» TIPS program cost approximately $2 million over 5.5 years» Looking region-wide at the number of low birth weight/ preterm births eliminated per year as a result of decreased smoking, and calculating those newborn hospital cost savings:

For a $2 mil investment, the TIPS program has led to a $9.5 million reduction in newborn hospital costs ($4.75 saved for every $1 spend), untold additional savings in long-term health and educational expenses, and significantly improved quality of life for women and children in the region.Looking at the percentage of smokers who receive TennCare (TN Medicaid program), and subtracting out the $2 million cost of the program, the state saved over $5 million in newborn costs alone over the 5.5 years, and an estimated additional $10 in medical costs over the first 5 years of life for the children born to the women who stopped smoking.

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Findings Related to Other Drug Use» Effects of pregnancy smoking vs. other

substance use among TIPS participants» Not wanting to rely on self-report for illicit drug

use (may be substantial under-reporting), restricted the sample to infants who had biological testing for substances at delivery (meconium) [oversampled substance users]

» Final sample contained 265 infants:˃ No cigarette/no drug use (n=46)˃ Cigarette use only (n=75)˃ Illicit drug use only (n=21)˃ Cigarette & illicit drug use (n=123)

» Drugs examined included amphetamines, barbiturates, benzodiazapines, cannabinoids, cocaine, and opioids

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Adjusted Birth Weights for the 198 Smokers:• Smoked Only (n=75) 3065 gm• Smoked AND Used Marijuana (n=39) 3068 gm• Smoked AND Hard Illicit Drug Use (n=84) 2902 gm• Test for group difference: F=3.39, p=.036• Adjusted Birth Weight Difference = 163 gm

Interpretation: Compared with those who both smoked and used hard illicit drugs, those who smoked but DID NOT USE HARD ILLICIT DRUGS had a 163gm gain in adjusted birth weight – a 5.6% difference.

Effect of Illicit Drug Use on Birth Weight

Findings Related to Other Drug Use

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Adjusted Birth Weights for the 105 Hard Illicit Drug Users:

• Hard Drug Use Only (n=21) 3207 gm

• Hard Drug Use AND Smoked (n=84) 2890 gm

• Test for group difference: F=6.28, p=.014

• Adjusted Birth Weight Difference = 317gm

Interpretation: Compared with those who both smoked and used hard illicit drugs, those who used hard illicit drugs BUT DID NOT SMOKE had a 317 gm gain in adjusted birth weight – an 11.0% difference.

Effect of Smoking on Birth Weight

Findings Related to Other Drug Use

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Adjusted Birth Weights: No smoking/No Drug Use (n=46) 3248 gm Smoked AND Hard Drug Use (n=84) 2896 gm Test for group difference: F=17.42, p<.001 Adjusted Birth Weight Difference = 352gm

Interpretation: Compared with those who both smoked and used hard illicit drugs, those who USED NEITHER SUBSTANCE had a 352 gm gain in adjusted birth weight – a 12.2% difference.

Effect of BOTH Smoking and Hard Illicit Drug Use on Birth Weight

Findings Related to Other Drug Use

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» Pregnancy substance use was NOT associated with early delivery in the current sample

» Pregnancy marijuana use did not adversely impact birth weight BEYOND the effects of cigarette smoking

» This finding suggests that for pregnant women who both smoke and use marijuana, quitting marijuana use while continuing to smoke will not lead to improved birth outcomes

Findings Related to Other Drug Use

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» Pregnancy smoking had twice the impact on birth weight as illicit drug use

» Findings support the assertions of those who have suggested that pregnancy smoking may be at least as detrimental to the developing fetus as the use of many illicit drugs

» Findings also support the need to direct more attention toward increasing pregnancy smoking cessation efforts

» Pregnant women should be strongly advised of the risks of continued smoking, and should be assisted in their efforts to eliminate the use of ALL substances, including tobacco

Bailey BA, McCook, JG, Hodge A, McGrady L. Infant birth outcomes among substance using women: Why quitting smoking during pregnancy is just as important as quitting harder drugs. Maternal and Child Health Journal, 16:414-422, 2012.

Findings Related to Other Drug Use

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After the Intervention» HEPPA–Health Education for Prenatal Providers

in Appalachia (www.etsu.edu/heppa)» Targeting 4 distressed counties in WV, 4 in TN» Working with health care providers and others

who work with pregnant women to address poor child health and developmental outcomes by decreasing pregnancy smoking and substance use and increasing breastfeeding rates

» Provide community training in 5 A’s, educational sessions and materials, coordination of county providers and services

» Nearly 200 professionals trained, networks established; analysis of evaluation data underway

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After the Intervention» HEPPA–Health Education for Prenatal Providers in Appalachia (www.etsu.edu/heppa)» Findings were encouraging:

˃ Nearly 100 professionals who work with pregnant women in the four target counties attended a training

˃ Established a web-page with training and resource materials – over 1000 visits

˃ Established a FaceBook page for networking – over 50 friends˃ 3 month follow-up showed substantial increases in knowledge, skills,

attitudes, and administration of interventions in practice+ The percentage of participants who reported they were “Very

Comfortable” talking with pregnant women about smoking went from 22% prior to training to 64% 3 months after training

+ The percentage of participants who reported they were “Very Skilled” at smoking cessation counseling went from 16% prior to training to 62% 3 months after training

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Currently Available Resources» Funding for the most successful, and most costly aspect of the

program has ended (dedicated counselors/case managers)» Support for prenatal practices is still available to provide 5 A’s

training and consultation» Website and resource materials still available; TN Quitline» Nursing student training continues» HEPPA Program resources still available» Recent distribution of tobacco settlement money to Tennessee

county health departments – many of which are looking to fund cessation counselors or provide training and support to providers

» Educated physicians and nurses helping prenatal patients quit smoking

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Summary» Smoking during pregnancy has significant immediate and long

term adverse consequences for those exposed prenatally» Pregnancy smoking is a significant problem in rural Appalachia

and contributes to the poor newborn and childhood outcomes» Regional resources to help pregnant smokers are limited » Interventions are effective, producing substantial cost savings, but

those that work can be costly:˃ Dedicated counseling and case management˃ Nurse/student nurse training and support˃ Region-wide efforts involving prenatal practices, hospitals, health

departments, higher education, and community

» Pregnancy smoking cessation should be a high priority in any efforts to improve birth outcomes and child health/development

Tobacco Use in Pregnancy: Effects and Intervention

Beth Bailey, PhDAssociate Professor of Family Medicine

Director, Division of ResearchEast Tennessee State University