Alice Ordean MD, CCFP, MHScMedical Director, T-CUP, SJHC

November 30, 2011

Prevalence of tobacco use during pregnancy

Effects: obstetrical, fetal, neonatal, adolescence

Screening and assessment for nicotine dependence

Smoking cessation interventions during pregnancy

Tools and resources

22% of women report smoking in the 3 months prior to pregnancy or before becoming aware of pregnancy (16% smoking daily, 6% occasionally)

Proportion of women who smoked during pregnancy declined to ~11% in third trimester (7% smoked daily & 4% occasionally)

Proportion of daily smokers who smoked 10+ cig/day declined during pregnancy & increased again postpartum

Daily smokers in T3: 58% smoked 1-9 cig/day, 42% smoked >10 cig

80% of women try to quit or reduce smoking

Ref: Canadian Maternity Experiences Survey, 2009

47% of those who quit during pregnancy had resumed smoking by 6 months postpartum – overall 16% were smoking after delivery (12% daily, 4% occasionally)

During pregnancy, 23% of women lived with someone who smoked

Reasons for smoking postpartum: stress mgmt, time for herself, losing weight

Younger age: <24 years old

Educational level: less than high school education

Multiparity

Low socioeconomic status: Women living in a household at or below the low income cut-off

Marital status: single mothers

Variations by provinces & territories Ref: Canadian Maternity Experiences Survey, 2009

Dose-response relationship documented: effects influenced by amount & duration of smoking

Increased risk of :

Spontaneous abortion -1.5x, ectopic pregnancy Intrauterine growth restriction (IUGR) – 2x Preterm delivery, premature rupture of membranes Placental complications (placenta previa, placental

abruption) 2x Infant morbidity & mortality (eg. stillbirth) mostly

due to increased IUGR and preterm deliveryRef: www.pregnets.org

Products of tobacco smoke are concentrated in breast milk (up to 5x greater than in blood)

Smoking can decrease quality & quantity of breast milk by inhibiting milk let-down feeding difficulties and early weaning from BF

Breastfeeding is protective against respiratory illnesses BF is encouraged among smokers

Nicotine levels increase after smoking; half-life of nicotine is 95 minutes women should avoid smoking just before and during feeding

Effects linked to maternal smoking during pregnancy and second-hand smoke exposure

Increased risk of:

More cranky or colicky babies Sudden infant death syndrome 2-5x Respiratory illnesses eg. bronchitis, pneumonia Asthma & allergies up to 400x Middle ear infections Neurodevelopmental (eg. poorer math & reading

skills) & behavioural problems (eg. attention-deficit/hyperactivity disorder)

Pregnancy ComplicationsNeonatalEffects

Long-TermEffects

Subfertility (female and male)Ectopic pregnancy (outside the uterus)Spontaneous abortion (miscarriage)Preterm labourPremature rupture of membranesPlacental problems (previa & abruption) Growth restriction

Low birth weight (on average ~200 grams smaller)Increased perinatal mortalityIncreased admission to the neonatal intensive care unit (NICU)Sudden infant death syndrome (SIDS) Decreased volume of breast milk and duration of breastfeeding

Childhood respiratory illnesses (asthma, pneumonia, bronchitis)Other childhood medical problems (ear infections)Learning problems (reading, mathematics, general ability)Behavioral problemsAttention deficit hyperactivity disorder (ADHD)

[1] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005

Cigarette smoking during pregnancy and breastfeeding is associated with numerous negative effects – preventable outcomes by cessation of smoking at any point during pregnancy

Pregnancy represents a window of opportunity to help woman make a change

Women with the following characteristics are more likely to quit smoking:

higher educated lighter smokers those who live with nonsmokers those with stronger beliefs in the harms of

smoking those experiencing their first pregnancy

1. Woman-centred care: care focused on woman’s needs in context of social, economic life circumstances eg. Focus on woman’s health before and during pregnancy

2. Harm reduction: focus on reducing harm to woman & fetus from effects of smoking eg. Reduced smoking, nicotine replacement tx

3. Reducing stigma to help engage pregnant smokers: deal with pressures to quit smoking

Offer a variety of cessation approaches and intensities depending on stage of change

Address the postpartum period in the prenatal intervention

Build-in partner support

Encourage smoking reduction as an alternative to smoking cessation for those unable to quit

ASK: “Do you smoke? How many cigarettes do you smoke?”

If she does not smoke, inquire about environmental tobacco exposure

“Does anyone smoke around you or your children?”

If yes, then educate about ways to stop or decrease exposure to second hand smoke

Assess motivation/readiness to change behaviour

Ask: “How do you feel about your smoking? Are you planning to quit?”

“On a scale of 1-10 how would you rate your motivation to quit smoking at this time?

“On a scale of 1-10, how important is it for you to quit at this time?”

“On a scale of 1-10, how confident are you that you can quit smoking at this time?”

16

Precontemplation

Contemplation

Preparation

Action

Maintenance

Pro

gres

sR

elapse

Pre-contemplative: no interest in quitting, or “in more than 6 months”

Contemplative: thinking about quitting in 1-6 months

Preparation: planning to quit in next month

Action stage: in process of cutting down or has set a quit date

Maintenance: quit more than 6 months ago

Amount & duration smoked (pack-years), pattern of smoking

Degree of dependence eg. Fagerstrom test – time from waking up to first cigarette

Reasons for smoking and for quitting

Past experience with quitting: what worked and what did not, relapse triggers

Other addictions, medical problems, psychiatric problems, medications

1. Counselling: tailor intervention according to stage of change & focus on moving patients along stages of change and enhancing confidence to quit

2. Pharmacotherapy: suppress withdrawal symptoms & cravings

Nicotine replacement therapies Bupropion (Zyban) Varenicline (Champix)

Smoking cessation should be encouraged for all pregnant, breastfeeding and postpartum women

A smoke-free home environment should also be encouraged to avoid exposure to second-hand smoke

Counselling is recommended as first line treatment for smoking cessation during pregnancy and breastfeeding (some evidence for increased quitting rates)

Stage of change Intervention

Pre-contemplative Initiate discussion about impact of smoking on patient’s life, encourage smoke free house/car & provide educational materials

Contemplative Increase motivation to quit: offer help, complete decisional balance – pros & cons of smoking and quitting

Preparation Help find right treatment: plan for quitting eg. past quit hx, barriers & smoking triggers, set quit date

Action Support & sustain cessation efforts: coping strategies , medications, follow-up visits

Maintenance Relapse prevention counselling

• Counselling: brief, delivered by range of practitioners; may be conducted by physicians, allied healthcare professionals (e.g. social worker, pharmacist), family home visitors, etc.

• Quit guides: take-home, patient-focused guide to quitting

• Buddy support: to provide social support

• Partner counselling/social context

• Education about pregnancy & smoking

During Pregnancy Make no-smoking rules for her home

Handling the challenge of partner smoking

Avoid triggers & remove “reminders”

Postpartum Explain to others that the same no-smoking

rules apply as in pregnancy

Be aware of what’s happening: discuss what she enjoyed about smoking vs. non-smoking

Be prepared to resist it: change past routines

Remember that it will not last long

Use a non-smoking alternative whenever feel the need to smoke eg. exercising, chewing gum, eating, using relaxation skills & other enjoyable activities eg. phoning a friend

Avoid other substances eg. coffee, alcohol

Assure patient that slips and relapses are normal: learning opportunity, not a failure

Identify triggers & develop a plan to cope with them

Maintain motivation and encourage positive self-talk to maintain self-confidence

Strengthen commitment

Get back on track

Partners, friends & family members should also be offered smoking cessation interventions

Despite preliminary evidence that continued smoking and relapse are more likely among pregnant women who have a smoking partner, there is limited data regarding the benefits of partner involvement in smoking cessation interventions for pregnant smokers

In non-pregnant populations, interventions to increase support did not find increased quitting rates

Second-line treatment options during pregnancy may include:

Nicotine replacement therapies Bupropion (Zyban) Varenicline (Champix)

Symptoms increase by 3-4 days after quitting smoking and last for 1 week

First symptoms: dysphoric or depressed mood, irritability, restlessness, anxiety, insomnia, fatigue, increased appetite

Lack of concentration and cravings may last for months

Symptoms worse in heavy smokers and those who smoke within 30 minutes of getting up

NRT can be considered as a second line option for individuals who cannot quit after counselling interventions

Intermittent dosing nicotine replacement therapies (such as lozenges/gum) are preferred over continuous dosing of a patch

There is limited evidence on harms associated with the use of nicotine replacement therapy (NRT) during pregnancy

Evidence from RCTs failed to find a difference in smoking cessation rates, but there may be some decrease in number of cigarettes smoked per day & improved pregnancy outcomes (lower rates of preterm delivery & low birth weight)

Benefits of NRT seems to outweigh potential risks; therefore, NRT should be considered when counselling has been ineffective.

Depression during pregnancy is a common occurrence and the use of Zyban (bupropion) may be appropriate to treat both smoking and depression

There is limited evidence on the effectiveness of bupropion for smoking cessation during pregnancy; only 1 prospective study demonstrated increased quitting rates with bupropion use during pregnancy

In addition, there is no evidence of harm related to the use of bupropion during pregnancy and therefore, it may be considered for use as an alternative to NRT for a subpopulation of pregnant smokers.

No evidence regarding safety of varenicline during pregnancy; therefore, its use during pregnancy is not recommended.

PREGNETS www.pregnets.org [specialized toolkit to address smoking cessation among pregnant & postpartum women]

CAN-ADAPTT www.can-adaptt.net [evidence- based clinical practice guidelines]

TEACH (Training enhancement in applied cessation counselling and health)“Helping Pregnant Smokers Stop Smoking: An Interactive Case Based Course [evidence-based training and continuing professional education]

CAMH Nicotine Dependence Clinic www.camh.net

Ontario Smokers Helpline 1-877-513-5333 Motherisk www.motherisk.org or 1-877-327-

4636

Clinical practice guideline & knowledge exchange network

Integrates practice, policy and research in a collaborative smoking cessation network

Goal: To inform the development of a Pan-Canadian clinical practice guideline (CPG) for smoking cessation

Dr. Peter Selby, Principal Investigator, CAN-ADAPTT Funded by the Drugs and Tobacco Initiatives Program, Health Canada

Smoking cessation should be encouraged to all pregnant and breastfeeding women. (GRADE = 1A)

During pregnancy and breastfeeding, counselling is recommended as first line treatment for smoking cessation.  (GRADE = 1A)

If counselling is found ineffective, intermittent dosing nicotine replacement therapies (such as lozenges, gum) are preferred over continuous dosing of the patch after a risk-benefit analysis. (GRADE = 1C)

Partners, friends and family members should also be offered smoking cessation interventions. (GRADE = 2B)

A smoke-free home environment should be encouraged for pregnant and breastfeeding women to avoid exposure to second-hand smoke. (GRADE: 1B)

Durham Region Health Department provides a number of services to promote and support

tobacco-free livingDRHD offers:

• A 6-week Support Group for smokers that want to quit using tobacco

• Telephone counselling

• Quit Kits for prenatal and postpartum women that contain self-help materials

• Information for new dads regarding quitting smoking and second-hand smoke

• Assistance for health care providers to develop comprehensive tobacco cessation strategies for their setting

• Information and resources regarding community supports available to facilitate tobacco cessation

Contact Durham Health Connection Line 905-666-6241 or 1-800-841-2729

Health Unit Actions:

Knowledge & skill training for all Chronic Disease & Family Health Department Staff

Implement 4A protocols◦ Information Request Line◦ Prenatal Programs◦ Healthy Babies Healthy Children◦ Post-partum Enhancement Program◦ Integrated into continuum of care for follow-up (family

home visitors & family health nurses) Focus on increasing access to cessation services by

developing community capacity to provide brief

interventions in a variety of settings

Partners with local health care professionals to:

Provide training & technical assistance to develop community capacity to provide interventions

Increase awareness of evidence-based cessation initiatives

Motivate local practitioners to implement evidence-based strategies (eg. 4A Protocol)

Increase the number of people contemplating, preparing & taking action to quit (particularly among youth, young men, & people with low SES)

One to one individual counselling appointments

Quit smoking groups Telephone counselling Provision of self-help

resources

Funded by Health Canada to March 2012

Support group for pregnant and post partum women who smoke

Facilitated by a Community Health Worker and Public Health Nurse

Free Childcare Free transportation $20 Gift card every week

Funded by ECHO: Improving Women’s Health In Ontario to March 2013

Free, confidential phone, online and text messaging services at 1 877 513-5333 and SmokersHelpline.ca

English, French and interpreter service

Accept Fax Referrals from health care providers through Quit Connection program (www.smokershelpline.ca/refer)

Specialized protocols in place to serve pregnant and post-partum women

Ann Burke705-726-8032 ext. 3226aburke2@ontario.cancer.ca

7% of women age 20 to 44 years were pregnant or breast feeding at the time of their first contact with Smokers’ Helpline

Quit Coaches operate from a perspective that is woman-centred rather than fetus-centred

◦ While we do not exclude concern for the fetus, the focus is on the woman’s health and goals.

Use Motivational interviewing to support an identity shift from smoker to non-smoker

Expanded proactive service offered, surrounding the due date◦ Can receive up to 14 proactive calls from a Quit Coach