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Smoking Cessation & Pregnancy
Susan A. Albrecht, PhD, RN
Donna D. Caruthers, PhD(c), RNUniversity of Pittsburgh
School of NursingSupported by: National Institute of Nursing Research
# RO1-NR03233
Presentation Overview
• Significance of smoking in the obstetrical patient
• Brief overview of findings for smoking cessation during pregnancy
• Review of study findings for smoking cessation with pregnant teenagers
• Implications for future work
SignificanceAdults• 25% of adults smoke regularly• 12.3% pregnant adults smoke during pregnancy
(Matthews, NVSS, 49:7, 2001)
Teens• 1/3 of all teens smoke• Teens at risk
Rural adolescents & Inner city femalesHighest rates of smoking in pregnancy (26%)
(Matthews, NVSS, 49:7, 2001)
Teen Smoking & Pregnancy
0
5
10
15
20
25
30
35
<15 15 - 17 18 - 19 Other
Allegheny County, 1995Age (Years)
%
Teen Health Risks
• Respiratory system damage
• Nicotine Addiction• Risk for other drug use (Surgeon General, 1994)
• Impairs physical endurance & performance• Decreased overall health with increases in
healthcare visits (Arday,et al., Am J of Health Promotion,1995;10(2): 111-116)
Health Risks – Teen Pregnancy
• U.S Highest teenage pregnancy rate of developed countries. (CDC, 1999)
• Low birth weight due to poor prenatal nutritional intake
• Preterm delivery • Obstetrical risks double with teen
smoking(ACOG Educational Bulletin, 1997;240.)
Obstetrical Health Risks & Smoking• Ectopic pregnancy
• Placenta previa
• Abruptio placenta
• Preterm delivery
• Perinatal mortality
• Low birth weight – 2 times greater in smokers
• Intrauterine growth retardation(ACOG Educational Bulletin, 1997;240.)
Fetus and Infant Health Risks• Low birth weight• Sudden Infant Death Syndrome (SIDS)• Respiratory illnesses
Pulmonary, Otitis Media, Asthma
• School problemsLower scores on spelling & reading
tests Decreased attentionRisk for hyperactive behavior
• Increased Hospitalizations (Pollack, H.A., Am J Public Health, 2001; 91(3) &
ACOG Educational Bulletin, 1997;240.)
Background – Pregnant Adult
Smoking during pregnancy:Is it a temporary act?
At least 1/3 of all women who quit during pregnancy relapse before delivery. (Ershoff, 1995, Am J Prev Med)
Most women will relapse within 12 months of delivery. (Surgeon General, 2001)
2000 Clinical Practice Guidelines
• Guidelines state health care providers must screen and address for tobacco consumption with every smoker at every encounter
• Treatments as brief as three minutes are effective
• Use Five A’s to guide your efforts• Use Five R’s to guide your efforts with
patients unwilling to quit
Background – Pregnant Adult
Treatment types investigated• Harm Reduction – Exposure from spouse• Support for spontaneous quitters• Prenatal cessation programs• Relapse prevention programs
-Prenatal delivery
-Post delivery - telephone counseling
Predictors of Relapse
Adult Pregnant Smokers
• Dependence/Tobacco use
• Passive exposure (spouse)
• Not breast feeding
• Self-efficacy• Education
Tobacco Control 2000, 9; supplement
Developmental Theory
Jessor’s Theory of
Problem Behavior Development• Teens engaging in one type of problem
behavior are more inclined to participate in other problem behaviors.
• Problem behaviors (e g. Smoking) focus on the role of peers.
Problem Behavior Theory
Social Environment
System
Personality System
Behavior System
Perceived Environment
System
Adapted from Jessor, Donovan, & Costa (1991)
Treatment Efficacy
• What are the short and long term differences in smoking behaviors among pregnant adolescents randomly assigned to either:
Teen FreshStart (TFS),
Teen FreshStart with Buddy (TFS-B), or
Usual Care (UC)?
Effect of Booster Sessions
• What is the effect of booster sessions on smoking behavior 1 year after study entry?
Booster sessions were anticipated to increase cessation rates as measured by self-report and saliva cotinine when controlling for cessation treatment (TFS & TFS-B).
Predictors of Relapse• Does a model consisting of baseline
characteristics of social environment, personal, and perceived environmental factors predict adolescent smoking at 12 months following study entry(T4).
Variables
Independent Variables
• Treatment Group Assignment
• Telephone Booster Sessions
Dependent Variables• Smoking Abstinence (Objective & Subjective)
1. saliva cotinine & carbon monoxide
2. self-report of smoking behavior
Data Collection
• Baseline – T1
• Following 8 week intervention – T2
• 6 weeks postpartum – T3
• 1 year following baseline – T4
Study Entry Criteria
Inclusion Criteria• 14 - 19 years old
• 12 - 28 weeks pregnant
• Smokes one or more cigarettes/day
• Read & understood English
Exclusion Criteria• Pregnancy
complications
• Confined to home for medical reasons
Sample
On average, pregnant female subjects (n = 142) were:
• White (49%; 39%)
• Single (32%)
• 17 yrs. old (s.d. ± 1.3)
• Gestation of 19 weeks (s.d. ± 7.2)
Baseline Tobacco Use• Initiated smoking: 12 years (s.d. ± 2.3)• Regular smoker: 13 years (s.d. ± 2.1)• Cigarettes/day before
pregnancy: 15 (s.d. ± 9.3)• Current
Cigarettes/day: 7 (s.d. ± 4.6)• Nicotine Dependence (FTQ):
4 (s.d. ± 1.9)• Previous quit attempt: 78%
Other Baseline Problem Behaviors
0102030405060708090
Alcoholuse beforepregnancy
Currentuse of
alcohol
Marijuanause beforepregnancy
CurrentMarijuana
use
%
Ethnic Differences
02468
101214161820
# Cigarettesbefore
pregnancy
# Cigarettesduring
pregnancy
White
Black
p < .001 p < .001
Teen Fresh Start - Intervention
Topics of group sessions1-3: smoking patterns & effects on
mom & baby 4: quit day 5: first steps of recovery 6: using coping skills 7: shared experience 8: celebrating healthy choices
Relapse – Baseline to 1 Yr.
0
50
100
150
200
250
300
Baseline T 2 T 3 T 4
Sal
ivar
y C
otin
ine
ng/m
l
UC
TFS
TFSB
Group, Carbon Monoxide, Booster
0
2
4
6
8
10
12
14
BLCO 2nd CO 3rd CO 4th CO
UC
TFS
TFS-B
Bst - TFS
Bst - TFS-B
CO
le
vel p
pm
n = 34
Group, Cotinine, Booster
0
50
100
150
200
250
300
350
BLCOT 2nd COT 3rd COT 4th COT
UC
TFS
TFS-B
Bst - TFS
Bst - TFS-B
Cot
inin
e le
vel n
g/m
l
n = 38
Predictors of AbstinencePredictor SE p O.R. Conf.
Interval
Attitude
Parent vs Peer
.57 .18 .002 1.77 1.2 – 2.5
Constant -5.03 1.17
Test of Model X2 = 12.9, 3df, p <.005
Predictors of AbstinencePredictor SE p O.R. Conf.
Interval
Attitude
Parent vs Peer
.44 .21 .035 1.54 1.03 – 2.3
ETOH Pre-
Pregnancy
1.7 .78 .029 5.46 1.2 – 25.0
Constant -5.13 1.34
Test of Model X2 = 11.9, 4df, p <.018
Conclusions
• Short-term tobacco abstinence was effective with the TFS-Buddy intervention.
• Neither the TFS or TFS-Buddy interventions were effective for long-term tobacco abstinence.
• Tobacco abstinence during teenage pregnancy may be one event in which a teen’s peers and parents are in agreement.
Implications
• Further research is needed to improve tobacco abstinence for pregnant adolescents and adults.
• Teens with heavy dependence may benefit from nicotine replacement medications, but research is lacking in this area.