Tobacco, Alcohol and Drug Use in Childbearing Families

1. Tobacco, Alcohol and Drug Use in Childbearing Families Presented by: Dona Dei, RN/MSN ddei@marchofdimes.com

2. Smoking and Pregnancy

3. Substance Abuse During Pregnancy (SAMHSA, 2005) • Based on data collected from surveys of U.S. households in 2003 and 2004: • 18.0 percent of pregnant women reported that they smoked cigarettes. • 11.2 percent drank some alcohol. • 4.5 percent engaged in binge drinking. • 0.5 percent engaged in heavy drinking. • 4.6 percent used some kind of illicit drug.

4. Pregnancy and Smoking • 16.2 % of women smoke cigarettes • Smoking is an important determinant of health status and a major contributor to prematurity, low birth weight and SIDS

6. Smoking Risks in Pregnancy • Ectopic pregnancy • Intrauterine growth restriction • Placenta previa • Abruptio placentae • PROM • Spontaneous abortion • Preterm delivery • SIDS (up to 4 timesgreateroccurrence in smoking mothers)

7. Smoking and Pregnancy • Black smokers had substantially higher cotinine concentrations at all levels of cigarette smoking than White smokers. • Caraballo, JAMA 280:135, 1998

8. Smoking and Child Health

9. Cost of Complicated* Births

10. Substance Abuse During Pregnancy(SAMHSA, 2005) (Continued) • Pregnant women are less likely to use substances than their peers. • The exception is pregnant women aged 15 to 17; this substance use rate is 26 percent for pregnant women, compared with 19.6 percent for nonpregnant women.

11. Smoking and Pregnancy • Smoking during pregnancy is responsible for: • 20% of all LBW • 8% of preterm births • 5% of all perinatal deaths • Pregnant smokers compared to nonsmokers are: • 2.0-5.0 times as likely to experience PPROM • 1.2-2.0 times as likely to deliver preterm • 1.5-10 times as likely to deliver a SGA infant • 1.5-3.5 times as likely to deliver a LBW infant

12. Substance Abuse During Pregnancy (SAMHSA, 2005) (Continued) • Rates of substance abuse in pregnancy have stayed constant. • Pregnant women’s tobacco use decreased from 2002 to 2004, while alcohol and illicit drug use increased (SAMHSA, 2005).

13. Substance Abuse During Pregnancy (SAMHSA, 2005) • Women more prone to substance abuse: • Earn below poverty level • Were exposed to violence as a child • Have a history of domestic abuse • Suffer depression or other mental health problems • Have less than a high school education • Are unmarried • Are unemployed • Are involved with the criminal justice system

14. Substance Abuse During Pregnancy (SAMHSA, 2005) • Substance use is highest in the first trimester. • The most common form of substance use in pregnancy is smoking among White women. • Because tobacco, alcohol and drug use in pregnancy occurs across all demographic groups, nurses should screen all women.

15. The Problem of Addiction • Addiction does not occur unless psychological and social conditions promote continued drug use. • Nurses are better able to provide support and nonjudgmental care if they respect substance users as reasonable and intelligent persons whose judgment has been impaired.

16. Genetic Contributions to Addiction • The propensity to specific addictions has been linked to particular genes. • Genetic differences may affect the seriousness of biological consequences of substance exposure in pregnancy.

17. Addiction as a Biopsychosocial Problem • Addiction is produced when biological, psychological and social predispositions combine with exposure to substances and an environment that supports regular substance use. • Nursing assessment should focus on a broad scope of personal, familial and social stressors and coping skills.

18. Women’s Treatment Issues • Women may be more predisposed to addiction than men. • Women are adversely affected by smaller amounts of alcohol and drugs than men. • Women are more likely than men to lack resources to pay for drug treatment.

19. Women’s Treatment Issues (Roberts & Dunn,2003) (Continued) • Women’s treatment programs must take a whole-life approach and address: • Low self-esteem • The need for social services and parenting support • Protection from violence • Training in relationship issues and coping skills • Vocational and legal assistance

20. The 5 A’s • 1. Ask about tobacco use • 2. Advise to quit • 3. Assess willingness to make a quit attempt • 4. Assist in quit attempt • 5. Arrange follow-up

21. Ethical Challenges • A conflict exists between the woman’s right to autonomy over her body and behavior and the nurse’s sense of obligation to prevent harm to the fetus. • If nurses are part of an enforcement system instead of advocates for women’s needs, women may avoid prenatal care and social services.

22. The Nurse’s Role • In prenatal and acute care settings, nurses should: • Thoroughly assess psychosocial risks • Conduct mutual goal-setting to minimize harm associated with psychosocial risks • Offer support and respect • The sense of being valued can help drug users begin to make changes.

23. Tobacco Use in Pregnancy: Maternal Effects • Cigarette smoking is the most common form of substance abuse in pregnancy. It is linked to: • Decreased fertility • Spontaneous abortion • Placenta previa • Placental abruption • Ectopic pregnancy • Preterm premature rupture of membranes (PPROM) • Preeclampsia

24. Tobacco Use in Pregnancy: Fetal Effects • Impaired transfer of oxygen and nutrition • Long-term cognitive function and increased risk of brain damage • Chronic low-level hypoxia • Intrauterine growth restriction (IUGR) • Preterm delivery • Low birthweight (LBW) in term infants

25. Tobacco Use in Pregnancy: Neonatal Effects • Impaired respiratory function in premature infants • Low neurobehavior scores and higher withdrawal-symptom scores • Asthma, respiratory illness and pneumonia • Infections of the middle ear • Increased risk of cancer and SIDS

26. Introducing Social Issues • The nurse should begin to explore the woman’s home situation, including: • Stress related to work, finances, family and pregnancy • Satisfaction with the amount and kind of support in her social network • Feelings about self-esteem and ability to cope with stressors

27. Three-question Substance-use Screen • Have you ever drunk alcohol? • How much alcohol did you drink in the month before pregnancy? • How many cigarettes did you smoke in the month before pregnancy?

28. Substance Abuse Assessment • In no case should urine or blood testing be used without consent. • If a woman admits to substance abuse, testing is not needed to confirm the presence of a problem.

29. Tobacco Use Assessment • Women generally report their smoking status fairly accurately. • The Fagerstrom Test for Nicotine Dependence is used to assess the level of addiction to tobacco (Heatherton et al., 1991).

30. The Fagerstrom Test for Nicotine Dependence • How soon after you wake up do you smoke your first cigarette? • Do you find it difficult to refrain from smoking in places where it is forbidden? • Which cigarette would you hate most to give up? • How many cigarettes per day do you smoke? • Do you smoke more frequently in the first hours after waking than during the rest of the day? • Do you smoke if you are so ill that you are in bed most of the day?

31. Principles of Brief Intervention:Problem Recognition and Goal-Setting • Provide feedback on problems, symptoms and historical events that suggest a substance abuse problem. Offer simple, realistic information about the effects on mother and baby. • Advise the woman to stop (or cut down) using substances. • Emphasize that any action taken is the woman’s choice. • Give options for treatment. • Get agreement from the woman on at least one action to take.

32. Follow-up During Pregnancy and Postpartum • At each visit, the nurse should: • Ask the woman about psychosocial • issues. • Progress in reducing substance use • Use of treatment options • Health changes • Impart good news.

33. Harm Reduction • Harm reduction is an important principle for care of substance users (MacMaster, 2004). • When abstinence is not achieved, reducing the harm of substance use is an important goal.

34. Recognizing the Full Scope of the Problem • Few substance users are able to quit on their first attempt. • Nurses should view any progress as worthwhile and recognize that recovery is a lifelong process. • Women need to develop entirely new social support systems.

35. Smoking Treatment: Follow-up During Pregnancy • One of the least expensive and most effective forms of follow-up is telephone contact. • Follow-up should focus on how the effort is going; support and reinforcement for even small successes; suggestions to overcome obstacles; and health progress reports.

36. Smoking Treatment: Reducing Postpartum Relapse • Thirty percent to 70 percent of smokers who quit during pregnancy relapse by 1 year postpartum (Secker-Walker et al., 1998). • Postpartum follow-up is essential. • Nurses can offer the same tips they gave to pregnant smokers, with emphasis on planning ahead to avoid excessive fatigue and isolation.

37. Summary • Nurses can: • Provide life-changing interventions for vulnerable families • Advocate for increased funding for women’s substance-abuse treatment • Work to reduce harmful stigma • Advocate for healthy environments that reduce exposure to substances