Maternal & Child Health and Smoking Your name, institution, etc. here YOUR LOGO HERE (can paste to each slide) …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 Teachable Moments Before, During and Beyond Pregnancy 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? 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 Counseling Intervention 5 As A A sk about tobacco use A A ssess willingness A rrange for follow-up dvise to quit ssist in quit attempt R efer Community Resources 1-800-QuitNOW A 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 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 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 Congratulate patient 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 Advise A 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 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 A ssist: in Quit Attempt 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) 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. 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.” Personalized Plan for Patients 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 women Relevant to pregnancy Relevant to unborn child Relevant to baby after birth Relevant 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 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.” 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 Asthma Otitis Media Fire-related Injuries SIDs Bronchiolitis Meningitis Childhood Infancy In utero Low Birth Weight Stillbirth Neurologic Problems Influences to Start Smoking Adolescence Nicotine Addiction Adulthood Cancer Cardiovascular Disease COPD 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) 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 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 Hospitalized 4 days & 6 months pregnant, admitted medicated to stop contractions to hospital for pre-term labor Smokes a pack & a half a day and has smoked for 6 years Boyfriend smokes 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 Had several prior quit attempts Occasionally uses Has a son who has asthma smokeless tobacco instead of cigarettes Concerned about stress with Wife encourages him to work & home life and avoiding weight gain Not sure about trying again John is sick with bronchitis quit 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 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