PREGNANT SMOKERS PREGNANT SMOKERS ––TREATMENT STRATEGIES TREATMENT STRATEGIES
Elyse R. Park, Ph.D., MPHElyse R. Park, Ph.D., MPHMassachusetts General Hospital Massachusetts General Hospital
Departments of Psychiatry & Institute Departments of Psychiatry & Institute for Health Policyfor Health Policy
Tobacco Research & Treatment CenterTobacco Research & Treatment Center
Faculty DisclosureFaculty Disclosure
Dr. Park has an Investigator initiated award from Dr. Park has an Investigator initiated award from Pfizer in which the medication, Pfizer in which the medication, VareniclineVarenicline, was , was provided for a pilot smoking cessation trial for provided for a pilot smoking cessation trial for lung cancer patients.lung cancer patients.
Learning ObjectivesLearning Objectives
Identify risk factors for prenatal smoking Identify risk factors for prenatal smoking and postpartum relapseand postpartum relapse
Review 3Review 3--levels of brief behavioral levels of brief behavioral smoking cessation interventionssmoking cessation interventions
Review pharmacological treatmentsReview pharmacological treatments
Health Risks of Tobacco Use Health Risks of Tobacco Use During and After PregnancyDuring and After Pregnancy
Smoking Smoking duringduring PregnancyPregnancySignificant evidence that smoking causes:Significant evidence that smoking causes:
StillbirthStillbirthPreterm birthPreterm birthPlacental abruptionPlacental abruptionSIDS SIDS
Associated with increased risks of:Associated with increased risks of:Spontaneous abortionsSpontaneous abortionsEctopic pregnanciesEctopic pregnanciesPlacenta Placenta previaprevia MMWR, 2004;Cnattingius, NTR, 2004MMWR, 2004;Cnattingius, NTR, 2004
Smoking during PregnancySmoking during PregnancyLow BirthweightLow Birthweight
0
5
10
15
20
25
30
35
LBW
(%)
0 1-5 6-10 11-15 16-20 21-30 31+Cigarettes per Day
Simpson, Am J OBGYN, 1957Simpson, Am J OBGYN, 1957
Smoking Smoking afterafter PregnancyPregnancy
Increased risk in children of smokersIncreased risk in children of smokersSudden Infant Death Syndrome (SIDS)Sudden Infant Death Syndrome (SIDS)Hospitalization in 1Hospitalization in 1stst year of lifeyear of lifeSerious respiratory infectionsSerious respiratory infections
(e.g., (e.g., bronchiolitisbronchiolitis, pneumonia), pneumonia)
OtitisOtitis mediamediaAsthmaAsthma
WHY DO SMOKERS KEEP SMOKING?
Pharmacologic addiction to nicotinePharmacologic addiction to nicotine
Psychological dependence on smokingPsychological dependence on smokingBehavioral cuesBehavioral cues (meals)(meals)Coping with stress, emotionsCoping with stress, emotions (anger)(anger)
Mood regulationMood regulation
NICOTINE WITHDRAWAL SYMPTOMSNicotine cravingNicotine cravingIrritability, anger, impatienceIrritability, anger, impatienceRestlessnessRestlessnessDifficulty concentrating Difficulty concentrating InsomniaInsomniaAnxietyAnxietyDepressed mood Depressed mood Increased appetiteIncreased appetite
FINANCIAL COSTS OF FINANCIAL COSTS OF PRENATAL SMOKINGPRENATAL SMOKING
SmokingSmoking--attributable costs by pregnant attributable costs by pregnant smoker = $880smoker = $880
For each pregnant women who quits For each pregnant women who quits smoking, Medicaid saves $1274smoking, Medicaid saves $1274
1% decrease in smoking prevalence 1% decrease in smoking prevalence would save U.S. $21 million in direct would save U.S. $21 million in direct medical costs in first yearmedical costs in first year
Clinical Practice Guideline, 2008Clinical Practice Guideline, 2008
Who Smokes in Pregnancy?Who Smokes in Pregnancy?
How prevalent is prenatal smoking?How prevalent is prenatal smoking?
1111--22% of U.S. women smoke throughout 22% of U.S. women smoke throughout pregnancy pregnancy
State prevalence range 26% (WV)State prevalence range 26% (WV)-- 6% (AZ6% (AZ))
42% of females < 12 years of school smoke 42% of females < 12 years of school smoke during pregnancy during pregnancy
25% of pregnant Medicaid recipients are 25% of pregnant Medicaid recipients are smokerssmokers
Risk Factors For Smoking in Risk Factors For Smoking in PregnancyPregnancy
Less educationLess education
Young Young
White White
MedicaidMedicaid
Partner who smokesPartner who smokes
Smoking Cessation Smoking Cessation MethodsMethods
PHARMACOLOGICAL PHARMACOLOGICAL TREAMENTTREAMENT
SMOKING CESSATION METHODS2008 US Public Health Service Guidelines
Effective treatments exist Effective treatments exist
More is better but brief intervention worksTreating tobacco is highly cost-effective
Counseling (individual / group / telephone)- Effective for adolescents
Pharmacotherapy – use combinationsCombination is better than either one alone
SSmoking Cessation during Pregnancymoking Cessation during PregnancyPharmacologic InterventionsPharmacologic Interventions
The efficacy and safety of these The efficacy and safety of these pharmacological approaches during pharmacological approaches during pregnancy is unknown pregnancy is unknown
No medication has been observed in a No medication has been observed in a sufficiently large pregnant population to sufficiently large pregnant population to determine what might occur with largedetermine what might occur with large--scale usescale use
PHARMACOLOGIC TREATMENT2008 U.S. Public Health Service Guideline
Nicotine replacement (Class D)Gum Skin patch Nasal spray Inhaler Lozenge (no category rating)
Bupropion SR (Zyban,Wellbutrin SR) (Class C)
Varenicline (Class C)
In nonIn non--pregnant smokers, NRT and pregnant smokers, NRT and buproprionbuproprioneach double cessation compared to behavioral each double cessation compared to behavioral methods alone.methods alone.
In very limited studies in pregnant women, NRT In very limited studies in pregnant women, NRT was not associated with adverse outcomes, but was not associated with adverse outcomes, but did have a shortdid have a short--term influence on fetal breathing term influence on fetal breathing movements and fetal heart rate variability.movements and fetal heart rate variability.
Nicotine most likely has adverse effects on the Nicotine most likely has adverse effects on the fetus; smoking exposes women to nicotine plus fetus; smoking exposes women to nicotine plus other chemicals that are injurious.other chemicals that are injurious.
PHARMACOLOGIC TREATMENT2008 U.S. Public Health Service Guideline
VARENICLINEVARENICLINE
NonNon--nicotine medication; interferes with nicotine medication; interferes with nicotine receptorsnicotine receptorsAgonist & antagonist function; reduces Agonist & antagonist function; reduces pleasure gained from smoking as well as pleasure gained from smoking as well as withdrawal symptomswithdrawal symptomsFDA approval FDA approval –– 20062006
VARENICLINEVARENICLINE
Unknown safety with pregnant womenRecent safety warningsRecent safety warnings–– Warnings of use in individuals with Warnings of use in individuals with
serious psychiatric illnessserious psychiatric illness–– FDA public health advisory (2/2008)FDA public health advisory (2/2008)(http://www.fda.gov/bbs/topics/NEWS/2008/NEW(http://www.fda.gov/bbs/topics/NEWS/2008/NEW
01788.html)01788.html)
CHOOSING THE RIGHT CHOOSING THE RIGHT PHARMACOLOGICAL TREATMENT PHARMACOLOGICAL TREATMENT
FOR PATIENTSFOR PATIENTS
Oral substitutes good for cravingsOral substitutes good for cravings
Nasal spray works quicklyNasal spray works quickly
Nicotine inhalers mimic smokingNicotine inhalers mimic smoking
Patches are convenientPatches are convenient
Prescription pros & consPrescription pros & cons
DepressionDepression
BEHAVIORAL TREATMENTBEHAVIORAL TREATMENT
2008 U.S. DHHS CLINICAL 2008 U.S. DHHS CLINICAL PRACTICE GUIDELINESPRACTICE GUIDELINES
Because of the serious risks of smoking to the Because of the serious risks of smoking to the pregnant smoker and fetus, whenever possible pregnant smoker and fetus, whenever possible pregnant smokers should be offered personpregnant smokers should be offered person--toto--person psychosocial interventions that exceed person psychosocial interventions that exceed minimal advice to quit.minimal advice to quit.–– Psychosocial interventions are twice as effective Psychosocial interventions are twice as effective
than usual carethan usual care
Clinicians should offer effective tobacco Clinicians should offer effective tobacco dependence interventions to pregnant smokers dependence interventions to pregnant smokers at the 1at the 1stst prenatal visit as well as throughout prenatal visit as well as throughout the course of pregnancy. the course of pregnancy.
COUNSELING MODEL - ACOG (2000)
ASK
ADVISEASSESSASSISTARRANGE
COUNSELING MODEL – 1-3 minute brief intervention
ASK
ADVISEREFER with self-help material
ASKASK about smoking at every visitabout smoking at every visit
HOWHOW you ask mattersyou ask matters……
Deception rates, confirmed by comparing Deception rates, confirmed by comparing results of biochemical tests with selfresults of biochemical tests with self--reports, reports, are high. They reach 50% in some populations. are high. They reach 50% in some populations.
Alabama SCIP, 1998Alabama SCIP, 1998
Recommended QuestionRecommended QuestionWhich best describes your cigarette smoking? Which best describes your cigarette smoking?
I have NEVER smoked or smoked less than 100 I have NEVER smoked or smoked less than 100 cigarettes in my lifetimecigarettes in my lifetimeI stopped smoking BEFORE I found out I was pregnant I stopped smoking BEFORE I found out I was pregnant and I am not smoking nowand I am not smoking nowI stopped smoking AFTER I found out I was pregnant I stopped smoking AFTER I found out I was pregnant and I am not smoking nowand I am not smoking nowI smoke some now, but CUT DOWN since I found out I I smoke some now, but CUT DOWN since I found out I was pregnantwas pregnantI smoke regularly now, about the same as before I I smoke regularly now, about the same as before I found out I was pregnant.found out I was pregnant.
Mullen, Am Mullen, Am JlJl ObstetObstet GynecolGynecol, 1991, 1991
ADVISE every smoker to stop
“Quitting smoking is the most important action you can take for your health and your baby’s health”
Strong and clearBe positive - benefits of quitting
REFER smokers
Face-to-face counseling – group or individualTelephone counseling
New York State Smokers' Quitline: New York State Smokers' Quitline: 11--866866--NYNY--QUITS QUITS (1(1--866866--697697--8487)8487)
Hospital-based smoking cessation consultsWebsites:
www.nysmokefree.com
COUNSELING MODEL – 4-10 minutes
ASK
ADVISEASSESSASSISTARRANGE
ASSESS
Patient’s motivation to quit smoking
Risk perceptions
Social support
ASSESS readiness to quit
“If we give you some help, are you willing to try?”
Precontemplation “I like to smoke…”
Contemplation “I want to quit, but…”
Preparation “I’m ready to quit”
Assess Assess –– risk perceptionsrisk perceptions
““Can you tell me what you think about Can you tell me what you think about the risks of smoking for yourself?the risks of smoking for yourself?””
“…“…your baby?your baby?””
Assess Assess –– supportsupport
Emotional supportEmotional support
Smoking specific supportSmoking specific support
ASSISTSMOKERS READY TO QUIT
Set a quit date
Help make a treatment planGive a pregnancy-tailored bookletOffer social supportIdentify trigger situations
ASSISTSMOKERS NOT READY TO QUIT
Review health risks to mother and fetus
Educate about quitting process
Recommend no smoking around family
Address smoking at every prenatal visit
Assure follow-up during the first week of a quit; this is the critical periodSet follow-up appointmentRemember to address postpartum!
ARRANGE follow-up
COUNSELING MODEL – 10-30 minutes
ASK ADVISEASSESSASSISTARRANGE
ASSESS & ASSIST
Motivation to quit smoking
Risk perceptionsSocial support
Smoking environment
Confidence & importance
Pros & cons of smoking
Other health behaviors
Precontemplation: “I don’t want to quit”
Cognitive ProcessesKnowledge & AttitudesPerceived riskSmoking environment & support
• Elicit patient’s attitudes and beliefs about smoking• Provide information and personalized feedback• Increase patient’s perception of risks due to
current behavior
→DON’T GIVE ADVICE ABOUT WHAT THE PATIENT CAN DO TO MAKE CHANGES
Contemplation: “I’d like to quit, but I really like smoking”
Cognitive ProcessesKnowledge & Perceived riskSmoking environment & supportPros and ConsBarriersConfidence & importance
• Try to tip balance in favor of change• Try to strengthen confidence
→ BEHAVIORAL CHANGES ARE UNLIKELY TO WORK
Preparation: “I’m ready to quit, butI’m not sure how to do it”
Add Behavioral ProcessesOvercoming barriersIncreasing social support
• Strengthen commitment/motivation for change• Help patient to develop a feasible change plan• Discuss potentially difficult situations• Refer to behavioral or pharmacological treatment
→ CONSIDER DEVELOPING SMALL BEHAVIORAL CHANGES
Action & Maintenance: “I’ve quit/I’m a nonsmoker”
Continue cognitive & behavioral processes
•Strengthen commitment/motivation to change (review motivation & confidence)
• Review behavioral plan (check barriers, support)• Refer to behavioral or pharmacological treatment
if needed to stay quit• Discuss positive changes observed since quitting
(review pros & cons)
→ IDENTIFY RELAPSE RISKS
THE ROLE OF PROVIDERSTHE ROLE OF PROVIDERS
Obstetric providers often miss opportunities to Obstetric providers often miss opportunities to counsel smokers during prenatal & postnatal counsel smokers during prenatal & postnatal care care
www.TalkToYourPatients.orgwww.TalkToYourPatients.org
PROVIDER INTERVENTIONSPROVIDER INTERVENTIONS
MOMS STUDY & MEDICATIONSMOMS STUDY & MEDICATIONS
Cessation medications were not discussed Cessation medications were not discussed or recommended in the trial protocol. or recommended in the trial protocol.
EndEnd--ofof--pregnancy assessment asked pregnancy assessment asked subjects about subjects about
–– Use of smoking cessation methods Use of smoking cessation methods during that pregnancyduring that pregnancy
–– Whether prenatal provider discussed Whether prenatal provider discussed cessation methods during the pregnancycessation methods during the pregnancy
OB PROVIDER ADVISE & ASSISTOB PROVIDER ADVISE & ASSIST90
79
0102030405060708090
100
% of prenatal sm
okers reporting action
Advised to stop Assist
Park et al., SRNT, 2004
OB PROVIDER ASSISTANCE TO QUIT
101915
2737
66
0102030405060708090
100
Counseled
Given
materials
Methods
Gum
Patch
Zyban
% of prenatal sm
okers reportingaction
Park et al., SRNT, 2004
CESSATION MEDICATION DISCUSSED CESSATION MEDICATION DISCUSSED AND USED DURING PREGNANCYAND USED DURING PREGNANCY(End of pregnancy survey, N=296)(End of pregnancy survey, N=296)
29.3
10.1
0
10
20
30
40
%
Prenatal providerdiscussedmedication use
Smoker usedmedication inpregnancy
Rigotti, Park et al, 2007
Postpartum RelapsePostpartum Relapse
Postpartum Smoking CessationPostpartum Smoking Cessation
0102030405060708090
100
0 1 2 3 4 5 6
Months from Delivery
% A
bsta
inin
g
Mullen, AJPH, 1990Mullen, AJPH, 1990
77--DAY POINT PREVALENCE SMOKINGDAY POINT PREVALENCE SMOKING
0
2738
49
60
0
10
20
30
40
50
60
70
BL 6 week 12 week 18 week 24 week
Time Period
Perc
enta
ge
% smoking/Study N
Park et al., 2008
Mean Support by Smoking Status at 24 weeks
3BL 6 12 24Weeks Postpartum
Supp
ort S
core
smokers' emotional support nonsmokers' emotional supportsmokers' smoking-specific support nonsmokers' smoking-specific support
OB PROVIDER DISCUSSED MOOD OB PROVIDER DISCUSSED MOOD & SMOKING& SMOKING
54 52
42
24
0102030405060708090
100
% of prenatal quitters reporting action
Mood Smoking Mood Smoking
Park et al., 2008PRENATAL POSTPARTUM
CONCLUSIONSCONCLUSIONSPrenatal smoking can cause significant health Prenatal smoking can cause significant health and financial consequencesand financial consequences
The efficacy & safety of pharmacological The efficacy & safety of pharmacological smoking cessation treatment for pregnant women smoking cessation treatment for pregnant women is unknownis unknown
Brief obstetricianBrief obstetrician--delivered behavioral treatment delivered behavioral treatment can be effective at helping pregnant smokers quitcan be effective at helping pregnant smokers quit
Obstetricians can play an important role in Obstetricians can play an important role in helping their pregnant and postpartum patients to helping their pregnant and postpartum patients to quit & stay quitquit & stay quit