Maternal & Child Health and Smoking

1. Maternal & Child Health and Smoking Your name, institution, etc. here YOUR LOGO HERE(can paste to each slide)

2. …dedicated to eliminating children’s exposure to tobacco and secondhand smoke

3. Objectives Discuss fetal/newborn and maternal risks of maternal tobacco use Identify who is at greater risk of smoking during pregnancy and to identify some of the unique issues of pregnancy Acquire knowledge about pharmacotherapy and its role in smoking cessation in pregnancy Provide a brief smoking cessation intervention during pregnancy and post partum period

4. The Evidence Is Clear! When a woman quits smoking during pregnancy, her chances of having an uncomplicated pregnancy and healthy baby are dramatically increased

5. Risks for Women Who Smoke Reproductive health problems Infertility Conception delay Pregnancy complications Menstrual irregularity Earlier menopause Compromised immune system Respond differently to nicotine Cancer Less likely to breast feed Osteoporosis Thrombosis with use of oral contraceptives

6. Prenatal/Neonatal Outcomes Miscarriage Fetal death Pre-term deliveries Low birth weight baby Ectopic pregnancies Placenta previa and placental abruption SIDS Birth Defects(cleft lip/palate, heart defects, webbing)

7. A Call to Action: “Smoking is the most modifiable risk factor for poor birth outcomes”

8. 2008 CPG Recommendation “Because of the serious risk of smoking to the pregnant smoker and fetus, whenever possible smokers should be offered person-to-person psychosocial interventions that exceed minimal advice”

9. 2008 CPG Recommendation Although abstinence early in pregnancy will produce greatest benefits to the fetus and expectant mother, quitting at any point in pregnancy can yield benefits… clinicians should offer effective interventions at first prenatal visit as well a throughout the pregnancy

10. Intervention Makes a Difference Smoking cessation intervention by clinicians improves quit rates Brief counseling (5 to 15 minutes total) can help many pregnant smokers quit A woman is more likely to quit smoking during pregnancy than at any other time in her life

11. Smoke Free Families What we knew in 2000 has stood the test of time For light to moderate smokers, extended or augmented counseling increases the likelihood of cessation The components of extended counseling are still supported Many enhancements have been tested but none have produced results compelling enough to power a change in recommendations

12. Preconception Care All Gynecology and primary care visits Help her quit during pregnancy Never too late to quit Smoke free home and car during pregnancy Smoke free public places and work place Avoid secondhand smoke 3rd trimester begin post partum discussion What are her intentions post partum? Teachable Moments Before, During and Beyond Pregnancy

13. Pregnancy: A Unique Time • Often more open to change • May have more support to quit while pregnant • May not be socially acceptable to smoke if pregnant • Excited, ambivalent, afraid • May have more stress if unplanned pregnancy • May have added financial burden even if planned

14. Post Partum Opportunities Prepare for post partum triggers, cues, depression Intervention during hospital stay Home visitors First pediatric appointment WIC Follow-up call by quit line or other counselors Post partum checkup Smoke free home and car

15. Counseling Intervention A A A A A R 5 As efer skabout tobacco use dviseto quit ssesswillingness ssist in quit attempt rrangefor follow-up • Community Resources • 1-800-QuitNOW

16. sk: About Tobacco Use A • Ask or verify responses in a non-judgmental way: • Identify smoking status • Counsel all smokers and recent quitters • Ask about Household and work environment • Discuss effects of SHS • If they smoke assess • Nicotine dependence • Patterns of use • Past quit attempts

17. Ask I stopped smoking before I found out I was pregnant and am not smoking now I stopped smoking after I found out I was pregnant and am not smoking now I have never smoked or have smoked fewer than 100 cigarettes in my lifetime I smoke about the same amount now as I did before I found out I was pregnant I smoke some now but have cut down since I found out I am pregnant Congratulate patient Advise Which of the following statements best describes your cigarette smoking?

18. ssess: Willingness to Make a Quit Attempt A • Assess patient’s level of interest in quitting and intention to take action to quit • Ask key questions

19. Importance and confidence scales “On a scale from 1 to 10, how important is it to you to quit smoking, where 1 is that it is not important at all and 10 is that it is very important.” 10=very important 1= not important

20. Importance and confidence scales “On a scale from 1 to 10, how confident are you that you could quit if you tried?” 1= not confident 10=very confident

21. ssist: in Quit Attempt A Preparation Stage (Willing to quit) • Help the patient with a quit plan • Provide practical counseling • Provide social support • Social support with treatment (Intra-treatment) • Social support outside treatment (Extra-treatment) • Provide supplemental materials (Self-learning materials, quitline, groups)

22. 2008 CPG statement and pharmacotherapy in pregnancy Safety is not categorical. A designation of “safe” reflects a conclusion that a drug’s safety outweigh its risks. Nicotine most likely does have adverse effects on the fetus during pregnancy. Although the use of NRT exposes the pregnant women to nicotine, smoking exposes them to nicotine plus numerous that are injurious to the fetus other chemicals. These concerns must be considered in the context of inconclusive evidence that cessation medications boost abstinence rates in pregnant women.

23. Pharmacotherapy and Pregnancy “If the increased likelihood of smoking cessation, with its potential benefits, outweighs the unknown risk of nicotine replacement and potential concomitant smoking, nicotine replacement products or other pharmaceuticals may be considered.”

24. Personalized Plan forPatients Note: Most materials available in Spanish

25. Patients Who Decline to Quit: Using the 5 Rs Relevance Risks Rewards Roadblocks Repetition

26. 5 Rs: Relevance (importance) Ask patient to identify how quitting might be personally relevant, such as: Relevant to her as a women Relevant to pregnancy Relevant to unborn child Relevant to baby after birth Relevant to money ?

27. Pros and Cons Good things about Smoking vs Bad Things about Smoking

28. Pros and Cons Hard things about quitting vs Benefits of Quitting

29. 5 Rs: Risks Ask, “What have you heard about smoking during pregnancy?” Reiterate benefits for her unborn baby and her other children Reiterate benefits to her Tell her that a previous trouble-free pregnancy is no guarantee that this pregnancy will be the same

30. 5 Rs : Rewards Your baby will get more oxygen after just 1 day Your clothes and hair will smell better You will have more money Food will taste better You will have more energy You will be healthier

31. 5 Rs : Roadblocks Negative moods Being around other smokers Triggers and cravings Time pressure Stress in her life

32. Overcoming Roadblocks: Negative Moods Engage in physical activity Express yourself (write, talk) Stress reduction/ relaxation Seek help with other psychological or social issues Think about pleasant, positive things Ask others for support

33. Overcoming Roadblocks:Other Smokers Ask a friend or relative to quit with you Ask others not to smoke around you Assign nonsmoking areas Leave the room when others smoke Keep hands and mouth busy

34. Overcoming Roadblocks:Triggers and Cravings Cravings will lessen within a few weeks Anticipate “triggers”: coffee breaks, social gatherings, being on the phone, waking up Change routine—for example, brush your teeth immediately after eating Distract yourself with pleasant activities: garden, listen to music

35. Secondhand Smoke

36. The Debate Is Over “The scientific evidence is now indisputable: secondhand smoke is not a mere annoyance. It is a serious health hazard that can lead to disease and premature death in children and nonsmoking adults.”

37. What is secondhand smoke? Secondhand Smoke (SHS) is the smoke that comes off the end of a smoking cigarette and the smoke that the smoker exhales

38. The Health Effects of Tobacco Use Asthma Otitis Media Fire-related Injuries Influences to Start Smoking SIDs Bronchiolitis Meningitis Childhood Adolescence Infancy Nicotine Addiction In utero Adulthood Low Birth Weight Stillbirth Neurologic Problems Cancer Cardiovascular Disease COPD

39. Secondhand smoke is toxic: 4000 chemicals > 50 Cancer-causing chemicals Formaldehyde Benzene Polonium Vinyl chloride • Toxic metals: • Chromium • Arsenic • Lead • Cadmium • Poison Gases: • Carbon monoxide • Hydrogen cyanide • Butane • Ammonia

40. SHS and Children: Short Term Health Effects • Respiratory tract infections such as pneumonia & bronchitis • Decreased pulmonary function • Triggers asthma attacks • Ear Infection (Otitis Media) • Tooth decay • House fires

41. SHS and Children: Long Term Health Effects • Sudden Infant Death Syndrome (SIDS) • Asthma • SHS exposure increases frequency of episodes and severity of symptoms • 200,000 annual cases of childhood asthma, attributed to SHS • Possible problems with cognitive functioning and behavioral development • More likely to become smokers

42. SHS and Adult Health Risks Nonsmokers who are exposed to secondhand smoke at home or at the workplace are at an increased risk of developing; • Lung cancer (20-30%) • Coronary heart disease (25-30%) • Acute respiratory problems

43. Case Study: Lisa • 17-year old • 6 months pregnant, admitted to hospital for pre-term labor • Smokes a pack & a half a day and has smoked for 6 years • Boyfriend smokes • Hospitalized 4 days & medicated to stop contractions • Contraction free & being discharged • Enjoys smoking & has no interest in quitting

44. Case Study: Linda • 27 years old • 3 children ages 6,4, and 2 who have asthma • Smokes 1 pack of cigarettes a day • Has smoked for 14 years • Expresses little interest in quitting

45. Case Study: John • Had several prior quit attempts • Occasionally uses smokeless tobacco instead of cigarettes • Wife encourages him to quit • Not sure about trying again • 32-year old father • Smokes a pack a day for past 14 years • John is sick with bronchitis • Has a son who has asthma • Concerned about stress with work & home life and avoiding weight gain

46. Case Study: Grace • 55-year old women • Has emphysema • Smokes a pack a day for the past 30 years • Has tried to quit several times in the past • Daughter and grandson lives with her

47. Need more information?The AAP Richmond Center www.aap.org/richmondcenter Audience-Specific Resources State-Specific Resources Cessation Information Funding Opportunities Reimbursement Information Tobacco Control E-mail List Pediatric Tobacco Control Guide