Treating Tobacco Use
During Pregnancy
Cecelia A. Gaffney, MEd
Dartmouth Medical School
May 16, 2005
1
Smoking Among Women
Health Consequences
Lung cancer is now the leading cause of
cancer death among US women,
surpassing breast cancer in 1987.
About 90% of all lung cancer deaths among
women who continue to smoke are
attributable to smoking.
2
Smoking Among Women
Health Consequences
Each year during the 1990s, US women
lost an estimated 2.1 million years of life
due to smoking attributable deaths.
Women who smoke also experience
gender-specific health consequences,
including increased risk of various
adverse reproductive health outcomes.
3
Quitting Smoking during
Pregnancy
“Only 18-25% of all women quit
smoking once they become
pregnant.”
“Between 13 and 17% of pregnant
women smoke in the United
States.”
The Health Consequences of Smoking, A Report of the Surgeon
General, 2004.
4
Call to Action
Smoking is the most modifiable risk
factor for poor birth outcomes
Successful treatment of tobacco
dependence can achieve:



20% reduction in low–birth-weight babies
17% decrease in preterm births
Average increase in birth weight of 28 g
5
Substance Use in Past Month
Among Women Aged 15-44 Years
25
20.6%
Prevalence (%)
20
15
10
2.4%
5
2.7%
0
Cigarettes
Alcohol
Illicit Drugs
National Household Survey on Drug Abuse, 1994-1996
6
Tobacco Use in Pregnancy
Maternal Harm
Possible causal association
- placenta previa
-spontaneous abortion
Probable causal association
-ectopic pregnancy
-preterm PROM
Causal association
-abruptio placenta
7
Tobacco Use in Pregnancy
Infant Harm
Causal association
-abruptio placenta
-small for gestational age
-preterm delivery
-Sudden Infant Death Syndrome
(SIDS)
-stillbirth
8
Effects of Maternal Smoking
During & After Pregnancy
“Compared with unexposed infants,
babies exposed to secondhand smoke
after birth are at twice the risk for SIDS,
and infants whose mothers smoked
before and after birth are at three to four
times greater risk.”
The Health Consequences of Smoking, A Report of the
Surgeon General, 2004.
9
Tobacco Exposure during
Infancy and Early Childhood
Causal association
-otitis media
-new and exacerbated
cases of asthma
-bronchitis and pneumonia
- wheezing and lower
respiratory illness
10
Cost of Complicated* Births
*Complications include hemorrhage from placenta previa, maternal infection, fetal
distress, malposition of the fetus
CDC. MMWR 1997;46:1048–1050
11
Cost-effectiveness of Smoking
Cessation Intervention
JAMA 1997;278:1759–1766
12
More Missed Opportunities
in Pregnancy
100%
81%
80%
80%
61%
60%
40%
21%
22%
25%
20%
Percent of
visits with
smoking status
identified
Percent of
smoker visits
with smoking
counseling
0%
Adult Patient
Visits
Pregnancy
(Adults)
Pregnancy
(Adolescent)
National Ambulatory Medical Care Survey, 1995; Thorndike, et al, 1998 JAMA 279:604-8; 1991 JNCI 91:1957-62
13
Intervention Makes a
Difference
Smoking cessation
intervention by clinicians
improves quit rates
Brief counseling works
better than simple advice
to quit
Intervention works best
for moderate (<20
cigarettes/day) smokers
A woman is more likely to
quit smoking during
pregnancy than at any
other time in her life
14
The Evidence-based Intervention
for Smoking during Pregnancy
Meta-analyses of randomized trials of
smoking cessation interventions with
pregnant smokers have concluded that:
A brief cessation counseling session of
5-15 minutes, when delivered by a trained
provider with the provision of pregnancy
specific, self help materials, significantly
increases rates of cessation among
pregnant smokers by 30 to 70 percent.
15
5 A’s Approach to
Smoking Cessation
Ask
Advise
Assess
Assist
Arrange
Adapted for pregnant
women by ACOG
16
Disclosure of Smoking Status
Recent studies confirm non-disclosure

Non-disclosure rates range from 3% to
13%
Concerns with biomarkers
Structured question still best method
17
Disclosure of Smoking
Status
Deception rates, as confirmed by
comparing results of biochemical tests
with self-reports, may be high among
pregnant women, reaching 23% in some
groups.
Windsor 2000, Mullen 1991
18
Improving Disclosure
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
19
Spontaneous Quitters
For the Woman Who Quits
Prior to or Upon Learning of
Pregnancy Reinforce her decision
to quit


Congratulate her on success in
quitting
Encourage her to stay quit
20
Smokers Not Ready
to Quit
5 R’s (or motivational interviewing)





Relevance
Risks
Rewards
Roadblocks
Repitition
21
Disclosure of Pregnant
Woman’s Exposure to SHS
Since you found out you were pregnant, about how
many hours a day, on average, are you in the same
room with someone who smokes?
Which of the following statements best describes the
rules about smoking inside your home while you were
pregnant?

No one was allowed to smoke anywhere inside your
home

Smoking was allowed in some rooms or at some
times

Smoking was permitted anywhere inside your home
Source: Adapted from The Pregnancy Risk Assessment Monitoring
System, The Centers for Disease Control and Prevention, 2002.
22
Disclosure of Child’s
Exposure to SHS
A validated, 5-part screening
instrument for assessing child’s
exposure has been developed and
tested





Does child’s mother currently smoke?
In the home?
Does child’s father currently smoke?
In the home?
Is your child exposed to cigarette smoke
on a regular basis (any exposure at least
one time per week) from anyone other than
the parents?
Source: Seifert JA, et al., 2002.
23
Treating Exposure to SHS
Intervention trials have focused on
parents of children with health problems
Mixed results from trials



Clinical settings in pediatric and group model
HMO have shown some success
More intensive interventions with
biofeedback of child’s cotinine level have
lead to significant reductions in exposure
Home based programs show mixed results
24
Treating Exposure to SHS
Good evidence to support use of medicinal
nicotine (MN) as a way to reduce exposure of
children
MN is least toxic way to get nicotine for both
the smoker and those living or working with
the smoker
Complete substitution of MN for smoking is
the goal
25
Treating Exposure to SHS
If no cessation or use of
MN, messages should be
 Don’t smoke in your
home
 Don’t smoke in your
car
Stress impact of
secondhand smoke
exposure on immediate
problem with child
 ear infections
 Bronchitis
 asthma
26
Web Resources
Smoke-Free Families:
smokefreefamilies.org
National Partnership:
helppregnantsmokersquit.org
27