Helping Pregnant Women Quit Smoking

1. Helping Pregnant Women Quit Smoking Best Practice Interventions Jolie Person Texas Department of State Health Services

2. Learner Centered Objectives • 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: 1 Competency: 0.5 Knowledge, 0.5 Communication

3. Video Clip - 25 Ways to Quit Smoking. Bill Plimpton

4. Prevalence of Tobacco Use • 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. Pregnancy Risk Assessment Monitoring System (PRAMS)

5. Predictors of Smoking During Pregnancy • A Smoking Partner • A Large Number Of Children • A High Rate Of Tobacco Consumption • Deficiencies In Prenatal Care Schneider, S., HuyC., Schutz J., & Diehl, K. (2010). Smoking cessation during pregnancy: a systematic literature review. Drug Alcohol Rev, 29.

6. Tobacco 101 • 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.

7. Types of Tobacco

8. Cancer-Causing Chemicals Formaldehyde: Used to embalm dead bodies Benzene: Found in gasoline Polonium 210: Radioactive and very toxic Vinyl chloride: Used to make pipes Toxic Metals Chromium: Used to make steel Arsenic: Used in pesticides Lead: Once used in paint Cadmium: Used to make batteries Poison Gases Carbon monoxide: Found in car exhausts Hydrogen cyanide: Used in chemical weapons Ammonia: Used in household cleaners Butane: Used in lighter fluid Toluene: Found in paint thinners There are over 4,000 chemicals in tobacco smoke599 AdditivesAt least 69 of those 4,000 chemicals are known to cause cancer

9. 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)

10. Smokeless Tobacco • 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.

11. 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

12. Adverse Effects of Tobacco Use Video Clip - Smaller babies http://www.youtube.com/watch?v=ypn3xpvA1eQ&feature=related

13. Adverse Effects of Tobacco Use …on mom • 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

14. Adverse Effects of Tobacco Use …on family members Children suffer from bronchitis, pneumonia, hyperactivity, middle ear infections, upper respiratory infections and are frequently hospitalized. 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.

15. Adverse Effects of Tobacco Use …on the unborn baby Of particular concern are carbon monoxide, nicotineand 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

16. Adverse Effects of Tobacco Use …on the newborn 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

17. Facts about Quitting Smoking • 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.

18. Interventions • Clinical Interventions • Five A’s • Brief Motivational Interviewing • Pharmacotherapy • Quit Line / Telephone Counseling

19. Clinical 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)

20. 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)

21. 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)

22. Five A’s • ASK the patient about smoking status at the first prenatal visit and follow-up with her at subsequent visits. • I have NEVER smoked or have smoked < 100 cigarettes in my lifetime • I stopped smoking BEFORE I found out I was pregnant… • I stopped smoking AFTER I found out I was pregnant… • I smoke some now, but I have cut down… • 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.

23. Five A’s • 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. • 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.

24. Five A’s • 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.

25. Five A’s • 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

26. Brief Motivational Interviewing 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.

27. Insufficient evidence of effectiveness Pharmacotherapy Nicotine Replacement Products • Patch • Gum • Inhaler • Nasal Spray • Lozenge Pharmaceuticals • Bupropion (Zyban)

28. Pharmacotherapy “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

29. 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

30. 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

31. Quit Line / Telephone Counseling 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

32. Best Practice

33. Tips for Quitting http://www.youtube.com/watch?v=yWTRiI8NsQA&feature=related http://www.youtube.com/watch?v=lf01Ti6bH8U

34. Tips for Quitting

35. Tips for Quitting It also helps to keep your hands and mouth busy.

36. Resources www.dshs.state.tx.us/tobacco

37. Resources BecomeAnEX.org Great tools to help people quit Online Quit Plan

38. Resources www.cdc.gov/tobacco

39. Resources Smokefree.gov or espanol.smokefree.gov

40. Resources Information for Smokers and Their Families 1-800-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 quit Become 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..

41. Information for Health Care Professionals American College of Obstetricians and Gynecologists: Smoking Cessation -- Smoking cessation resources for patients and providers Centers 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)

42. Information for Health Care Professionals Smoke-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.

43. Information for Health Care Professionals American 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.

44. Key Messages for Promoting Smoking Cessation • 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.

45. Thank you! Jolie Person Maternal and Child Health Program Texas Department of State Health Services Health Service Region 1 - Canyon, Texas jolie.person@dshs.state.tx.us 806-655-7151