1 / 48

Tobacco Use in Pregnancy: Effects and Intervention

Tobacco Use in Pregnancy: Effects and Intervention. Beth Bailey, PhD Associate Professor of Family Medicine Director, Division of Research East Tennessee State University. Effects of pregnancy smoking on exposed children Extent of the problem in rural Appalachia Intervention efforts

almira
Download Presentation

Tobacco Use in Pregnancy: Effects and Intervention

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Tobacco Use in Pregnancy: Effects and Intervention Beth Bailey, PhD Associate Professor of Family Medicine Director, Division of Research East Tennessee State University

  2. Effects of pregnancy smoking on exposed children • Extent of the problem in rural Appalachia • Intervention efforts • Intervention effectiveness • Current efforts & resources Overview

  3. seen during: Negatively Affects: Effects of Pregnancy Smoking

  4. Effects of Pregnancy Smoking • 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)

  5. Effects of Pregnancy Smoking Health Care Costs During the First Year of Life Premature Baby Healthy Baby $41,610 $2,766

  6. Effects of Pregnancy Smoking • 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) Growth deficits and health problems into childhood

  7. Effects of Pregnancy Smoking 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. Dietz, et al, 2010 Salihu, et al, 2003

  8. Effects of Pregnancy Smoking 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% Dietz, et al, 2010 Markowitz, 2008

  9. Effects of Pregnancy Smoking • 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 Long-term developmental problems

  10. Effects of Pregnancy Smoking • 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 What 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 exposure Brown & Graves, 2013

  11. Effects of Pregnancy Smoking In 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.

  12. Effects of Pregnancy Smoking Prospective 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/LBW • Rates 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.

  13. 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

  14. 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

  15. 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

  16. Extent of the Problem Percentage of Pregnant Women Who Smoke Rates increased from 2006-2007 <10% <10% 25% 28% 30-42%

  17. 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.

  18. 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

  19. 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%)

  20. Extent of the Problem Always Usually Sometimes Seldom Never ASK ADVISE ASSESS How often do you assess whether a pregnant smoker is willing to make a quit attempt? How often do you give clear, strong advice to quit to pregnant smokers? How often do you inquire about smoking status during prenatal visits? 20% 27% 63% ASSIST ARRANGE How often do you assist pregnant patients by encouraging the use of problem solving skills for smoking cessation? How often do you use counseling to help pregnant smokers quit? How often do you arrange for other assistance? 3% 17% 24%

  21. 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

  22. 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.

  23. 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

  24. The Intervention The TIPS program involved: • Physician training in providing smoking cessation counseling as a routine part of prenatal care • Nurse training in providing smoking cessation counseling as part of inpatient & outpatient services • Provision of prenatal counseling and case management services in high risk practices • Provision of a hospital-based counselor/case manager for admitted high-risk women and those post-partum • Education/training programs for nursing, public health, respiratory therapy, medical students; interdisciplinary community work • Community-based education and cessation workshops • Work with county health departments to integrate smoking screening and intervention • Development of self-help materials 5 FT staff, 4 PT staff; 4 FTE+ in students each term

  25. 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

  26. The Intervention Counseling/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

  27. 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)

  28. The Intervention Most Utilized Intervention Components

  29. Intervention Success 28% 10% 23% 65% 25% 49% 42% had at least one quit attempt Even among those who did not quit, average amount of smoking reduced from 17.7 cig/day to 8.6 cig/day 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).

  30. Intervention Success

  31. 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

  32. Intervention Success • Since the beginning of the TIPS project in mid-2007, pregnancy smoking rates in the region have decreased 28% 30.9 31.2 26.9 26.8 26.4 24.8 22.4 Percentage • 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

  33. 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

  34. 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

  35. 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%)

  36. 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.

  37. 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.

  38. 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

  39. Findings Related to Other Drug Use Effect of Illicit Drug Use on Birth Weight • 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.

  40. Findings Related to Other Drug Use Effect of Smoking on Birth Weight • 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.

  41. Findings Related to Other Drug Use Effect of BOTH Smoking and Hard Illicit Drug Use on Birth Weight • 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.

  42. Findings Related to Other Drug Use • 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

  43. Findings Related to Other Drug Use • 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.

  44. 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

  45. 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

  46. 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

  47. 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

  48. Tobacco Use in Pregnancy: Effects and Intervention Beth Bailey, PhD Associate Professor of Family Medicine Director, Division of Research East Tennessee State University

More Related