Maternal & Child Health and Smoking

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

Objectives

1) Discuss fetal/newborn and maternal risks of maternal tobacco use

2) Identify who is at greater risk of smoking during pregnancy and to identify some of the unique issues of pregnancy

3) Acquire knowledge about pharmacotherapy and its role in smoking cessation in pregnancy

4) Provide a brief smoking cessation intervention during pregnancy and post partum period

The Evidence Is Clear!

When a woman quits smoking during pregnancy, her chances of having an uncomplicated pregnancy

and healthy baby are dramatically increased

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

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)

A Call to Action:

“Smoking is the most modifiable risk factor for poor birth outcomes”

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”

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

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

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

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

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

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

sk about tobacco use

dvise to quit

ssess willingness

ssist in quit attempt

rrange for follow-up

Counseling Intervention

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5 As

Community Resources 1-800-QuitNOW

sk: About Tobacco Use

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

AA

Ask

Which of the following statements best describes your cigarette smoking?

I have never smoked or have smoked fewer than 100 cigarettes in my lifetime

I have never smoked or have smoked fewer than 100 cigarettes in my lifetime

I stopped smoking before I found out I was pregnant and am not smoking now

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 stopped smoking after I found out I was pregnant and am not smoking now

I smoke some now but have cut down since I found out I am pregnant

I smoke some now but have cut down since I found out I am pregnant

I smoke about the same amount now as I did before I found out I was pregnant

I smoke about the same amount now as I did before I found out I was pregnant

AdviseCongratulatepatient

ssess: Willingness to Make a Quit Attempt

Assess patient’s level of interest in quitting and intention to take action to quit

Ask key questions

AA

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.”

1= not important

10=very important

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

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)

ssist: in Quit AttemptAA

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.

“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.”

Pharmacotherapy and Pregnancy

Personalized Plan forPatients

Note: Most materials available in Spanish

Patients Who Decline to Quit: Using the 5 Rs

Relevance

Risks

Rewards

Roadblocks

Repetition

5 Rs: Relevance (importance)

Ask patient to identify how quitting might be personally relevant, such as:

Relevant to her as a womenRelevant to pregnancyRelevant to unborn childRelevant to baby after birthRelevant to money ?

Pros and Cons

Good things about Smoking

vs

Bad Things about Smoking

Pros and Cons

Hard things about quitting

vs

Benefits of Quitting

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

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

5 Rs : Roadblocks

Negative moods

Being around other smokers

Triggers and cravings

Time pressure

Stress in her life

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

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

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

Secondhand Smoke

“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.”

The Debate Is Over

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

The Health Effects of Tobacco Use

SIDsSIDsBronchiolitisBronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirthNeurologic ProblemsNeurologic Problems

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCardiovascular DiseaseCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

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

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

SHS and Children: Long Term Health Effects

Sudden Infant Death Syndrome (SIDS)

AsthmaSHS 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

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

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

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

Case Study: John

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

Had several prior quit attempts

Occasionally uses smokeless tobacco instead of cigarettes

Wife encourages him to quit

Not sure about trying again

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

www.aap.org/richmondcenter

Need more information?The AAP Richmond Center

Audience-Specific Resources State-Specific ResourcesCessation InformationFunding Opportunities

Reimbursement InformationTobacco Control E-mail List

Pediatric Tobacco Control Guide