Tobacco Cessation During Pregnancy: Prevalence and Interventions Van Tong, MPH Epidemiologist, CDC Division of Reprodu

1. Tobacco Cessation During Pregnancy: Prevalence and Interventions Van Tong, MPHEpidemiologist, CDC Division of Reproductive HealthOctober 21, 2009

2. CDC Division of Reproductive Health (DRH) Our mission is to promote optimal reproductive and infant health and quality of life by influencing public policy, health care practice, community practices, and individual behaviors through scientific and programmatic expertise, leadership, and support. Conduct epidemiologic, behavioral, demographic, and health services research. Support national and state-based surveillance systems to monitor trends and investigate health issues. Support development of scientific and programmatic development within states and other jurisdictions. Provide technical assistance, consultation, and training worldwide. Translate research findings into health care practice, public health policy, and health promotion strategies. Conduct epidemiologic, behavioral, demographic, and health services research. Support national and state-based surveillance systems to monitor trends and investigate health issues. Support development of scientific and programmatic development within states and other jurisdictions. Provide technical assistance, consultation, and training worldwide. Translate research findings into health care practice, public health policy, and health promotion strategies.

3. DRH work in tobacco use & pregnancy Monitor trends of tobacco use before, during and after pregnancy Conduct research on health outcomes & economic costs Evaluate interventions and promote effective interventions and policies Provide technical assistance to organizations http://www.cdc.gov/reproductivehealth/TobaccoUsePregnancy/

4. Presentation outline Prevalence and trend of prenatal tobacco use Overall Among pregnant teens Review recommendations for screening and treatment for tobacco cessation among pregnant women Provide cessation resources

5. Prenatal smoking is one of the most common preventable causes of poor birth outcomes Smoking among women causes Reduced fertility Preterm delivery Restricted fetal growth Preterm-related deaths and SIDS Second hand smoke (SHS) exposure Respiratory tract infections and SIDS

6. Risks of maternal smokeless tobacco use less studied However, data suggest an increased risk of Stillbirth Low birth weight Prematurity Preeclampsia Infant death

7. Percent of mothers who smoked during pregnancy in US, birth certificates 1990 � 2005* Here is the percent of mothers who smoked during pregnancy in the US. This is data collected from the birth certificates. Since 1990 to 2002, rates of smoking has decreased as measured by the birth certificate. From 1990 to 2002, prevalence of prenatal smoking decreased from 18.1% to 11.4%, approximately a 40% decrease In 2005, the smoking prevalence was 10.7% for 36 states, DC, & NYC, and 12.3% for 11 states. However, previous studies have shown that self-reported measures of smoking is an under-estimate of the true burden of the problem. Also we are not able to measure smoking before during and after pregnancy. Note: The data excludes California. In addition, as the 2003 revised birth certificate is being implemented, the smoking data is not comparable for trends to the old smoking question. In 2005, there were 11 states that had implemented the revised BC. (2004-7 states, 2003 � 2 states)Here is the percent of mothers who smoked during pregnancy in the US. This is data collected from the birth certificates. Since 1990 to 2002, rates of smoking has decreased as measured by the birth certificate. From 1990 to 2002, prevalence of prenatal smoking decreased from 18.1% to 11.4%, approximately a 40% decrease In 2005, the smoking prevalence was 10.7% for 36 states, DC, & NYC, and 12.3% for 11 states. However, previous studies have shown that self-reported measures of smoking is an under-estimate of the true burden of the problem. Also we are not able to measure smoking before during and after pregnancy. Note: The data excludes California. In addition, as the 2003 revised birth certificate is being implemented, the smoking data is not comparable for trends to the old smoking question. In 2005, there were 11 states that had implemented the revised BC. (2004-7 states, 2003 � 2 states)

8. Percent of mothers who smoked during pregnancy in US, birth certificates 1990 � 2003* For years where we have smoking prevalence for majority of states, we see that there is a significant decline of smoking rates. However, this is still far from our national goals of reaching 1% by 2010.For years where we have smoking prevalence for majority of states, we see that there is a significant decline of smoking rates. However, this is still far from our national goals of reaching 1% by 2010.

9. Prenatal smoking reported on 2003 US birth certificates by state Range of smoking 3.5% (DC) to 26.1% (WV).Range of smoking 3.5% (DC) to 26.1% (WV).

10. �still a problem

11. Smoking 3 months before pregnancy among live births in 25 PRAMS states* by maternal race/ethnicity and age, 2005 This graph shows smoking 3 months before pregnancy among women who delivered a live birth from the CDC PRAMS survey by maternal race/ethnicity and age. This represents 25 states. This graph highlights the disparity of smoking particularly by race and age. Smoking 3 months before pregnancy highest among teens among NH white, Alaska natives, and Asian Pacific islanders than other age groups. Rates among teens were 52% (NH Whites), 57% (AN), and 36% (AI), 28% (Asian and other race/ethnicity), and lowest among NH black and Hispanic at 11%.This graph shows smoking 3 months before pregnancy among women who delivered a live birth from the CDC PRAMS survey by maternal race/ethnicity and age. This represents 25 states. This graph highlights the disparity of smoking particularly by race and age. Smoking 3 months before pregnancy highest among teens among NH white, Alaska natives, and Asian Pacific islanders than other age groups. Rates among teens were 52% (NH Whites), 57% (AN), and 36% (AI), 28% (Asian and other race/ethnicity), and lowest among NH black and Hispanic at 11%.

12. Smoking during pregnancy among live births in 25 PRAMS states* by maternal race/ethnicity and age, 2005 This graph shows smoking during pregnancy. Overall smoking rates are lower compared to before pregnancy. Smoking during pregnancy highest among teens among NH white, Alaska natives, American Indian, Asian Pacific islanders, and other race/ethnicity. So basically all the racial/ethnic groups except for 2 groups (blacks and Hisp). Rates among teens were highest among AN (45%), then NH White (36%) and lowest among Hisp (5%). This graph shows smoking during pregnancy. Overall smoking rates are lower compared to before pregnancy. Smoking during pregnancy highest among teens among NH white, Alaska natives, American Indian, Asian Pacific islanders, and other race/ethnicity. So basically all the racial/ethnic groups except for 2 groups (blacks and Hisp). Rates among teens were highest among AN (45%), then NH White (36%) and lowest among Hisp (5%).

13. Smoking after delivery among live births in 25 PRAMS states* by maternal race/ethnicity and age, 2005 The rates of smoking go up after delivery compared to during pregnancy. Here smoking after delivery is also highest among the majority of racial ethnic groups. Rates among teens were highest among AN (45%), NH White (42%), AI (34%), and other (32%).The rates of smoking go up after delivery compared to during pregnancy. Here smoking after delivery is also highest among the majority of racial ethnic groups. Rates among teens were highest among AN (45%), NH White (42%), AI (34%), and other (32%).

14. Teens smoke more than any other age groups (1990-2002), but the rates may have fallen more in recent years1 Decreased from 20.3% in 1990 to 17.1% in 2002. 15 out of 45 states had significant increases in teen smoking during pregnancy from 1995-2002. Tobacco use associated with other higher risk behaviors Many young persons engage in sexual risk behavior and experience negative reproductive health outcomes2 Slide 8: Another group that has high pregnancy smoking rates are teens. Teens smoke more than any other age groups according to data from 1990-2002, but the rates may have fallen more in recent years Teen smoking during pregnancy (15-19 year olds) decreased from 20.3% in 1990 to 17.1% in 2002. In 2002, the rates of teens was similar to those women aged 20-24 years. Also from 1995-2002, 15 out of 45 states had significant increases in teen smoking during pregnancy. Tobacco use is associated with other higher risk behaviors, including higher risk sexual behavior. Slide 8: Another group that has high pregnancy smoking rates are teens. Teens smoke more than any other age groups according to data from 1990-2002, but the rates may have fallen more in recent years Teen smoking during pregnancy (15-19 year olds) decreased from 20.3% in 1990 to 17.1% in 2002. In 2002, the rates of teens was similar to those women aged 20-24 years. Also from 1995-2002, 15 out of 45 states had significant increases in teen smoking during pregnancy. Tobacco use is associated with other higher risk behaviors, including higher risk sexual behavior.

15. Tobacco use before, during, after pregnancy among Alaska Native and white women in Alaska, PRAMS 2000-2003 Less than 1.3% of white women used smokeless tobacco before, during, or after pregnancy. Therefore, not presented in table. In parts of Western Alaska, smokeless tobacco use during pregnancy is around 60%. Less than 1.3% of white women used smokeless tobacco before, during, or after pregnancy. Therefore, not presented in table. In parts of Western Alaska, smokeless tobacco use during pregnancy is around 60%.

16. 25%-50% spontaneously quit smoking after learning of pregnancy (Floyd et al., 1993; LeClere & Wilson, 1997; Severson et al., 1995; Tong, 2008) Another 12% quit later on; however, the majority of pregnant smokers cut down, but do not quit (Fingerhut et al., 1991) Of women who quit during pregnancy, about 70% relapse within 1 year following delivery (Fingerhut et al., 1991)

17. Benefits of cessation Early cessation is best: Women quit quit smoking by 16 weeks gestation have normal birth weight infants (MaCarther et al, 1988) Women who quit smoking by 30-36 weeks have near normal birth weight infants (Ahlsten et al., 1993) Women who quit smoking by 15 weeks, rates of spontaneous preterm birth and small for gestational age infants did not differ from those in non-smokers (McCowan 2009) Compared with women who smoked throughout pregnancy, first-trimester quitters reduced their odds of delivering (Polakowski 2009): preterm non-SGA newborn by 31% term SGA newborn by 55% preterm SGA newborn by 53%

18. 2008 USPHS recommendations for pregnant smokers Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. (Strength of Evidence = A) Although abstinence early in pregnancy will produce the greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.

19. Pharmacotherapy Pregnancy quit rates rarely exceed 18% Pharmacotherapies double quit rates in non-pregnant women Not enough information on the efficacy and safety of pharmacotherapies during pregnancy, so unable to assess benefit/risk (Fiore 2008) Psychosocial interventions should be first treatment option among pregnant smokers (Oncken, Nicotine Tob Res, 2009) More research needed on pharmacotherapies for cessation and pregnancy

20. 5A�s model for tobacco cessation Ask about tobacco use. Identify and document tobacco use status for every patient at every visit. Advise to quit. In a clear, strong and personalized manner urge every tobacco user to quit. Quitting early in pregnancy provides the greatest benefit to the fetus Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts. Arrange followup. For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

21. Screening for Tobacco Use in Pregnant Women Assess pregnant women�s smoking status using a multiple-choice question to improve disclosure (Fiore et al., Table 7.7, 2008) I smoke regularly now; about the same as before finding out I was pregnant I smoke regularly now; but I cut down after finding out I was pregnant I smoke every once and awhile I have quit smoking since finding out I was pregnant. I wasn't smoking around the time I found out I was pregnant, and I don't currently smoke cigarettes.

22. Relapse prevention Two meta-analyses of relapse prevention trials (both pre- and post-delivery) found no significant reduction in relapse. Postpartum relapse may be decreased by continued emphasis on the relationship between maternal smoking and poor health outcomes in infants and children (e.g., SIDS, respiratory infections, asthma, and middle ear disease)

23. Clinical interventions part of comprehensive tobacco control Clinic-based interventions have limited impact Universal implementation would only reduce prevalence by 0.8% (16.7% to 15.9%) (Kim et al 2009) Prenatal smokers harder to reach or treat Young, less educated, uninsured Heavier smokers Comprehensive tobacco control programs and policies (taxes, smoke-free laws, etc�) For example, cigarette taxes have an effect in reducing prenatal smoking rates (Ringel 2001, Colman 2003) The key question to ask, however, is how can we have the greatest impact on prenatal smoking cessation? One thing that we do know is that clinic based interventions have a limited impact on cessation. Clinic-based interventions, which include counseling and therapy, have a modest effect on quit rates. Unfortunately, medications such as nicotine replacement therapy have not been shown to be effective or safe for pregnant smokers. We estimated that if clinic-based interventions for pregnant women were universally implemented, there would only be a 0.8 percentage point reduction of smoking prevalence. Clinical interventions still have a significant place. In descriptive analyses, we have seen that prenatal smokers are more likely to be younger, less educated, entered prenatal care late, are uninsured, and have less access to health care resources. Also these smokers tend to be heavier smokers, more addicted, and possibly resistant to interventions. Therefore this population may be harder to reach, specifically in a clinic-based setting. The key question to ask, however, is how can we have the greatest impact on prenatal smoking cessation? One thing that we do know is that clinic based interventions have a limited impact on cessation. Clinic-based interventions, which include counseling and therapy, have a modest effect on quit rates. Unfortunately, medications such as nicotine replacement therapy have not been shown to be effective or safe for pregnant smokers. We estimated that if clinic-based interventions for pregnant women were universally implemented, there would only be a 0.8 percentage point reduction of smoking prevalence. Clinical interventions still have a significant place. In descriptive analyses, we have seen that prenatal smokers are more likely to be younger, less educated, entered prenatal care late, are uninsured, and have less access to health care resources. Also these smokers tend to be heavier smokers, more addicted, and possibly resistant to interventions. Therefore this population may be harder to reach, specifically in a clinic-based setting.

24. Telephone-based quitlines Quitlines eliminate barriers of access for women Free Services No transportation required Convenient and hours flexible Trained Staff Funded by CDC Available in all US states and territories National portal number (1-800-QUIT-NOW or 1-800-784-8669) All state QL have specialized materials for pregnant women; some are implementing postpartum counseling sessions

25. What do we know about telephone counseling and pregnant smokers? Evidence suggests that telephone counseling is effective, especially for light smokers (<10 cig a day) and for women who have already attempted to quit (McBride et al study AJPH 1999; Rigotti et al study Obstet & Gyn 2006;CA evaluation of quitlines among pregnant smokers)

26. Medicaid coverage of tobacco treatments Women enrolled in Medicaid have a smoking prevalence 3 times greater than prevalence among women who are privately insured (23.5% vs 7.9%) 7 state Medicaid programs (CA, IN, MN, NY, OR, PA, WV) cover all tobacco medications and one form of counseling, and 39 programs covered at least one form of treatment*

27. Resources For consumers Info on smoking and pregnancy: http://www.cdc.gov/Features/PregnantDontSmoke/ Tips on quitting: http://women.smokefree.gov/ Smoke free home pledge: http://www.epa.gov/smokefree/ 1-800-QUIT-NOW: http://1800quitnow.cancer.gov/ For clinicians and public health practitioners ACOG Clinician guide to helping pregnant women quit smoking: http://www.acog.org/departments/dept_web.cfm?recno=13 National Partnership for Smoke-free Families, consumer and practitioner resources: http://smokefreefamilies.tobacco-cessation.org/ Clean Air for Healthy Children: www.cleanairforhealthychildren.org

28. National Partnership for Smoke-free Families Clinician and consumer materials Native American Action Plan: tailor 5A�s for American Indian populations Medicaid Toolkit: health and economic costs and benefits of coverage, state activities Community and Worksite Toolkit: for employers http://smokefreefamilies.tobacco-cessation.org/

29. http://www.cdc.gov/Features/PregnantDontSmoke/

30. http://www.cdc.gov/mmWR/PDF/ss/ss5804.pdfFree hard-copies available upon request

31. Prenatal smoking rates declining in US, but disparities continue to exist Pregnant teens have high rates of smoking before, during, and after pregnancy Brief counseling and pregnancy-specific materials are effective for prenatal smoking cessation Coverage of cessation may be covered by Medicaid or can be accessed for free through state-based quitlines

32. Contact information