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Tobacco Cessation Interventions in Pregnancy

Tobacco Cessation Interventions in Pregnancy. Eric L. Johnson M.D. Physician Consultant North Dakota Tobacco Quitline/Quitnet Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences. Objectives.

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Tobacco Cessation Interventions in Pregnancy

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  1. Tobacco Cessation Interventions in Pregnancy Eric L. Johnson M.D. Physician Consultant North Dakota Tobacco Quitline/Quitnet Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences

  2. Objectives • Assess status of Tobacco Cessation Interventions for Pregnant Patients by OB/GYN providers in North Dakota • Translate this data into effective practice for OB/GYN providers • Understand current Tobacco Cessation Interventions for Pregnant Patients

  3. Tobacco Cessation Interventions by OB/GYN Providers in North Dakota • Study by UNDSMHS NORTHSTAR Research • 7 question survey • Mailed/e-mailed to 110 OB/GYN providers in North Dakota (OB/GYN, FP Physicians and Mid-levels) * • 73 surveys returned (65% of total) *list compiled with assistance from North Dakota Chapter of the American College of Obstetrics and Gynecology

  4. Results

  5. Do you provide care to pregnant patients in your practice?

  6. Do you assess pregnant patients for tobacco use?

  7. Do you offer tobacco cessation options to pregnant patients?

  8. Which of the following cessation tools are offered in your practice?

  9. Are any of these materials designed exclusively for pregnant women?

  10. Do you offer counseling to pregnant patients regarding tobacco cessation?

  11. What types of counseling do you offer pregnant patients for tobacco cessation?

  12. Do you prescribe medications to pregnant patients for tobacco cessation?

  13. Which medications do you prescribe to pregnant patients for tobacco cessation?

  14. Conclusions of Study • Most North Dakota OB/GYN providers are aware of Tobacco Cessation resources available to their patients who smoke • Most North Dakota OB/GYN providers offer Tobacco Cessation to their pregnant patients who use tobacco • Review of medication use for Tobacco Cessation in pregnant patients

  15. Why Tobacco Cessation? • Benefits in pregnancy and long term health • Reduce Cardiovascular Complications • Reduce Lung Disease • Reduce Cancer • Reduce Type 2 Diabetes • Economic benefit for individual and society

  16. Smoking in Pregnancy • Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11% • Smokers tend to be from lower socioeconomic and educational classes • WIC smoking population as high as 40%+ in North Dakota North Dakota Department of Health

  17. Smoking in Pregnancy • ~75% of pregnant smokers desire quitting • ~25-30% actually quit during pregnancy • ~50% resume after pregnancy • Smoking Cessation is most successful prior to pregnancy Ruggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51 Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8 Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.

  18. Complications of Smoking in Pregnancy • Fourfold increase in small for gestational age; Increased prematurity • Twice the rate of spontaneous abortions • Increased risk of abruptio placentae, placenta previa, premature and prolonged rupture of membranes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 George L, et al Epidemiology. 2006 Sep;17(5):500-5 Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003

  19. Complications of Smoking in Pregnancy • Intrauterine growth restriction • Stillbirth • Ectopic pregnancy • Infertility • Poor wound healing/surgical outcomes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.

  20. Fetal/Child Effects of Maternal Smoking in Pregnancy • Sudden infant death syndrome (SIDS) and increased respiratory illnesses in children • Possible Association with maternal smoking and ADHD/Behavioral Disorders • Congenital Anomalies (i.e., cleft lip/palate, cardiac) Linnett KM, et al Pediatrics 2005; 116: 462-467 Malik S, et al Pediatrics 2008 Apr;121(4):e810-6 Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90

  21. Issues in Smoking Cessation • Triggers • Mood changes • Withdrawal symptoms (most smokers underestimate) • Weight gain • Lack of support • Exposure to other smokers

  22. Smoking Cessation Interventions in Pregnancy • Brief Office Counseling • Smoking Cessation Class (i.e., Public Health) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

  23. Smoking Cessation Interventions in Pregnancy • 5 A’s • ASK about tobacco use (Tobacco as a vital sign) • ADVISE to quit • ASSESS willingness to make a quit attempt • ASSIST • those who are ready, with appropriate treatment • those who are not ready, with motivational counseling • ARRANGE for follow-up USPHS 2008

  24. Smoking Cessation Interventions in Pregnancy • Pregnancy affords a great opportunity • Multiple short term followup clinic visits • Phone calls/e-mail/quitline/quitnet • ASK every time • Options every time

  25. Pharmacotherapy

  26. Pharmacotherapy • Nicotine replacement therapy (NRT) • Gum • Patch • Spray • Inhaler • Lozenge • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • All are first line non-pregnant USPHS 2008

  27. Pharmacotherapy for Pregnant Smokers • NRT- Category D. Secreted in breast milk. Crosses placenta • Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester? • Varenicline (Chantix)- No data (yet) Oncken CA, Kranzler HR Nic Tob Res Nov 2009

  28. Pharmacotherapy for Pregnant Smokers • USPHS 2008 more limited recommendations vs USPHS 2000 • ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail

  29. Nicotine Replacement Therapy in Pregnancy • 6 randomized controlled trials 2000-2010 • 5 show possible benefit • Higher birth weight in 1 trial • Multimodal treatment-benefit? Oncken, C et al Obstetrics & Gynecology, 112(4), 859-867. Pollak, KI et al. American Journal ofPreventive Medicine, 33(4), 297-305. Hotham ED et al Addictive Behaviors, 31, 641-648. Hegaard HK et al Acta Obstetricia et Gynecologica Scandinavica, 82, 813-819. Kapur, B, et al Current Therapeutic Research, 62(4), 274-278. Wisborg, K, et al Obstetrics & Gynecology, 96(6), 967-971.

  30. Pharmacotherapy for Pregnant Smokers • NRT use must be risk vs benefit -heavy smoker, relapsers, other risk ? (i.e. CVD risk factors) -if NRT used, intermittent (gum, lozenge) -higher birth weight? • Buproprion? 1 study shows benefit * • Varenciline- not recommended presently *Chan B et al J Add Dis (24) 19-23 2005

  31. Pharmacotherapy for Pregnant Smokers • Smoking, Nicotine, and Pregnancy Trial • Currently underway (UK study) • Projected publication is 2013

  32. Behavioral Interventions

  33. In Office Counseling • Brief • No additional cost • Slightly increases quit rates in non-pregnant adults

  34. Classes • Maybe difficult to access in rural areas (variable) • Availability • Public Health, American Lung Association, Employers • Sometimes cost • Effective

  35. Quitlines • Free • Widely available • Effective • ND Quitline ~30% 13 month quitrate in general population • ND Quitline Free NRT for qualifying • MN Quitplan

  36. Online Services • Third party payers • ND Quitnet: Premium content to ND residents, launched Feb 2010 • ND Quitnet Free NRT

  37. 1-800-784-8669 nd.quitnet.com Free to all North Dakota Residents Free NRT for qualifying

  38. Quitlines • Other surrounding states have quitlines • 1-800-QUITNOW is universal in U.S. • Third Party Payers, Health Care Systems

  39. Nicotine Addiction • Smokers are addicts…………….. • Nicotine is a highly addictive substance…. • Successful treatment is based on addiction treatment principles…… • Behavioral/Cognitive/Motivational Interviewing • Pharmacotherapy (when appropriate)

  40. Challenges for Long-Term Tobacco Cessation • Pregnant smokers tend to not be “committed quitters” • Limitations of medication prescribing for pregnant/lactating smokers • Smoking is nicotine addiction, not just a bad habit

  41. Summary • Smoking is problematic in pregnancy • Long Term Health issues- mother and baby • Nonpharmacologic resources first line for most pregnant smokers • Possible limited role for NRT in select patients

  42. Review Articles • Crawford J, et al Smoking Cessation in Pregnancy: Why, How, and What Next Clinical Obstetrics &Gynecology June 2008 • Oncken CA, Kranzler HR What do we know about the role of pharmacotherapy for smoking cessation before or during pregnancy Nicotine Tob Res. Nov 2009

  43. See/Download My Slides: • http://www.med.und.edu/familymedicine/slidedecks.html Contact me: eric.l.johnson@med.und.edu ejohnson@altru.org 701 777 3811 or 701 795 2861

  44. Acknowledgements • Dr. Charles Christianson, NORTHSTAR, UNDSMHS • Jessica Behm, NORTHSTAR, UNDSMHS • North Dakota Chapter of the American College of Obstetrics and Gynecology • North Dakota Department of Health, Division of Tobacco Prevention and Control

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