Pregnant & Breastfeeding Women
CAN-ADAPTT Guideline Webinar Series
March 15, 2011
Guideline Section Lead:
Alice Ordean, MD, CCFP, MHSc
Bio and Disclosures
 Alice Ordean is an Assistant Professor in the
Department of Family & Community Medicine
at the University of Toronto and Medical
Director of the Toronto Centre for Substance
Use in Pregnancy (T-CUP).
 No disclosures.
Guideline Development Group
 Peter Selby, MBBS, CCFP, MHSc, FASAM;
 Gerry Brosky, MD, MSc, CCFP;
 Charl Els, MBChB, FCPsych, MMed Psych (cum
laude), Cert. ASAM, MRO;
 Rosa Dragonetti, MSc;
 Sheila Cote-Meek, BScN, MBA, PhD;
 Jennifer O’Loughlin, PhD;
 Paul McDonald, PhD, FRSPH;
 Alice Ordean, MD, CCFP, MHSc;
 Robert Reid, PhD, MBA
CAN-ADAPTT
 Guideline development, dissemination and
engagement project
 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
Funded by the Drugs and Tobacco Initiative, Health Canada
National Network
RESEARCH
Practice-informed
Research Agenda
Clinical Practice Guideline
Knowledge
Translation
Dissemination
& Engagement
PRACTICE
Initial LITERATURE REVIEW
for existing Clinical Practice Guidelines
5 Guidelines
Included
Version
1.0
COMPREHENSIVE LITERATURE SEARCH
87 Guidelines
Found
February 2009
Appraisal: AGREE
4 independent reviewers (practicing physicians)
All formally trained on AGREE instrument
The CAN-ADAPTT
program engaged the
Guidelines Advisory
Committee
Appraisal: AGREE Plus
8 Additional questions developed by CAN-ADAPTT
to understand the applicability of the recommendations
in the Canadian context
Highest
scoring
CPG’s
included
6 Guidelines Included
HIGH QUALITY CLINICAL PRACTICE GUIDELINES
U.S. Department of Health and Human Services Public Health Service: Treating Tobacco Use and Dependence (2008 Update),
New Zealand Smoking Cessation Guidelines (August 2007),
Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (March 2007),
Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (October 2003),
Institute for Clinical Systems Improvement. Tobacco use prevention and cessation for infants, children and adolescents (June 2004),
Institute for Clinical Systems Improvement Tobacco use prevention and cessation for adults and mature adolescents (June 2004).
HIGH QUALITY CLINICAL PRACTICE GUIDELINES
Clinical Approaches
• 7 clinical sections discussed
•Workshop held: November 1, 2009
• 100 CAN-ADAPTT members attended and provided
feedback
• The Guideline Development Group (GDG) reviewed the
section notes and determined revisions to the summary
statements.
Population Level approaches
Sections: Population level approaches to tobacco
cessation in Canada
Workshop/AGM: Oct 1st, 2010
Levels of Evidence
• Attributed levels of evidence and grades of
recommendation to each summary statement based on
GRADE principles
Network input
Version
2.0
Currently Posted
Input from
CAN-ADAPTT Network
Spring – Summer 2010
Version
3.0
Release Date
January 2011
Network Input
Background/Overview of
Evidence
 Existing evidence included CPGs from
Canada, USA, New Zealand, France and
UK
 Literature review in this specific
subpopulation has a limited number of high
quality trials with contradictory results
especially in area of pharmacotherapeutic
options
Background/
Overview of Evidence
U.S. Department of Health and Human Services
Public Health Service (2008)
 Because of the serious risks of smoking to the
pregnant smoker and the fetus, whenever possible
pregnant smokers should be offered person-toperson psychosocial interventions that exceed
minimal advice to quit. (Strength of Evidence = A)
 Although abstinence early in pregnancy will produce
the greatest benefits to the fetus and expectant
mother, quitting at any point in pregnancy can yield
benefits. Therefore, clinicians should offer effective
tobacco dependence interventions to pregnant
smokers at the first prenatal visit as well as
throughout the course of pregnancy. (Strength of
Evidence = B)
Background/
Overview of Evidence
New Zealand Ministry of Health (2007)
 Offer all pregnant and breastfeeding women who smoke
multi-session behavioural smoking cessation interventions
from a specialist/dedicated cessation service. (Grade=A)
 All health care workers should briefly advise pregnant and
breastfeeding women who smoke to stop
smoking. (Grade = A)
 NRT can be used in pregnancy and during breastfeeding
following a risk-benefit assessment. If NRT is used, oral
NRT products (for example, gum, inhalers, microtabs and
lozenges) are preferable to nicotine patches. (Grade=C)
Registered Nurses Association of Ontario (2007)
 Nurses implement, wherever possible, intensive
intervention with women who are pregnant and
postpartum. (Strength of Evidence = A)
Gap in Practice and Barriers
 Challenges in identification due to stigma
associated with smoking during pregnancy
 Pregnant & breastfeeding women frequently
receive inaccurate advice from health care
practitioners regarding the effects of
smoking during pregnancy and the safety of
smoking cessation interventions (e.g. NRT,
bupropion)
Table 1 – Negative Effects Associated with Cigarette
Smoking During Pregnancy and Breastfeeding
Cigarette smoking during pregnancy and breastfeeding is associated with numerous
negative effects on mother, fetus, infant and adolescent. [1]
Pregnancy Complications
Subfertility (female and
male)
Ectopic pregnancy (outside
the uterus)
Spontaneous abortion
(miscarriage)
Preterm labour
Premature rupture of
membranes
Placental problems (previa
& abruption)
Growth restriction
Neonatal
Effects
Long-Term
Effects
Low birth weight (on
average ~200 grams smaller)
Increased perinatal mortality
Increased 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 problems
Attention deficit
hyperactivity disorder
(ADHD)
[1] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005
Summary Statement #1
Smoking cessation should be encouraged for
all pregnant, breastfeeding and postpartum
women.
GRADE: 1A
Clinical Considerations
 Smoking cessation interventions should be
considered for the full spectrum of care from
preconception visit to 1 year postpartum.
 Smoking cessation counselling and care of
pregnant smokers may be conducted by
physicians, allied healthcare professionals (e.g.
social worker, pharmacist, community health
representatives), midwives, doulas, prenatal
advisors, postpartum supports, family home
visitors, and others.
Summary Statement #2
During pregnancy and breastfeeding,
counselling is recommended as first line of
treatment for smoking cessation
GRADE: 1A
Summary Statement #3
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
Clinical Considerations
 There is limited evidence on harms associated
with the use of nicotine replacement therapy
(NRT) during pregnancy. Until further
information is available, the risks and benefits of
smoking versus the use of NRT during
pregnancy must be considered when
counselling about smoking cessation options
Clinical Considerations
 NRT can be considered as a second line option
for individuals who cannot quit after counselling
interventions.
 There is some evidence from RCTs that NRT
may be efficacious in pregnancy in terms of
decreasing tobacco use and improving
pregnancy outcomes. No safety concerns
identified in these trials. Therefore, benefits of
NRT seems to outweigh potential risks;
therefore, NRT should be considered when
counselling has been ineffective.
Clinical Considerations
• 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. 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.
Summary Statement #4
Partners, friends and family members should
also be offered smoking cessation
Interventions.
GRADE: 2B
Clinical Considerations
 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 nonpregnant populations, interventions to increase
support did not find increased quitting rates.
Summary Statement #5
A smoke-free home environment should be
encouraged for pregnant and breastfeeding women
to avoid exposure to second-hand smoke
GRADE: 1B
Clinical Considerations
• Evidence from a recent systematic review and
meta-analysis demonstrated negative perinatal
outcomes (e.g. trend towards lower birth weight,
smaller head circumference and congenital
anomalies) associated with second-hand smoke
exposure. Therefore, pregnant and breastfeeding
women should avoid this environmental risk.
Research Gaps
 Relationship between smoking and infertility
remains uncertain
 Lack of information regarding use of
pharmacological agents such as Bupropion
and Varenicline as a smoking cessation aid
– need more research on the effectiveness
and safety
 Need more evidence of risk/benefit analysis
of various smoking cessation aids
Research Gaps
 Role of partners, family in smoking
cessation interventions needs to be defined
 Knowledge gaps of health care providers
needs to be addressed
Have additional feedback?
1. Join the network
2. Review the current version of the guideline
3. Provide your feedback online
• Clinical considerations; tools/resources
For more information
CAN-ADAPTT
Centre for Addiction and Mental Health
175 College St.
Toronto, ON M5T 1P7
T: 416-535-8501 ext. 7427
www.can-adaptt.net
Note: These presentation slides may be used or reproduced for
educational purposes only. Please acknowledge authorship of this
content to CAN-ADAPTT and CAMH.
Webinar Discussion: Suggested
Resources
 Medications and Mothers’ Milk by Dr. Thomas Hale
(2010)
 Drugs in Pregnancy and Lactation by GG Briggs, RK
Freeman and SJ Yaffe (2009)
 STARSS (Start Thinking About Reducing Secondhand Smoke) http:aware.on.ca/starss
 TEACH course “Helping Pregnant Women Quit
Smoking: A Woman-Centred Approach”
www.teachproject.ca/courses