Treating Tobacco Use During Pregnancy and Beyond

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Treating Tobacco Use During Pregnancy and Beyond

• Dr. Monica Scheibmeir
• Associate Professor School of Nursing
• University of Kansas Medical Center

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Treating Tobacco Use During Pregnancy and Beyond

• Overview of Information
• Maternal smoking
• Introduction to individual counseling techniques
  to use with pregnant smokers (5As)
• Pharmacological aids for smoking cessation
• Office-Based reminder systems

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Preaching to the Choir

• Why do we care if women smoke during their
  pregnancy?

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Preaching to the Choir

• Why do we care if women smoke during their
  pregnancy?
• Risks to infant
• prematurity, low birth weight, sudden infant
  death syndrome, cognitive delays in toddler
  years, increased risk of becoming a smoker

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Preaching to the Choir

• Why do we care if women smoke during their
  pregnancy?
• Risks to infant
• Risks to mother
• increased risk of spontaneous abortion
  prior to 28 weeks, placenta previa, and abruptio
  placenta

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Preaching to the Choir

• Why do we care if women smoke during their
  pregnancy?
• Risks to infant
• Risks to mother
• Economic costs to state/nation

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Neonatal Health Care Costs Related to Smoking
During Pregnancy
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Cigarette Smoking During Pregnancy
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Percentage of women age 15-19 who reported
smoking during pregnancy
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Percentage of women and girls who smoke while
pregnant according to race (1999)
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Percentage of women and girls who smoke while
pregnant according to age (1999)
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Theoretical Basis for the 5As

• Theory Transtheoretical Model of Change
• Researchers in the mid-70s began looking at
  various methods of counseling
• Studied patients with drug dependency (i.e.
  alcoholism)
• Interviewed patients undergoing treatment to see
  where they were at.

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Theoretical Basis for the 5As

• Major assumption When a person wants to change a
  behavior, he/she goes through stages or a
  serious of changes before reaching his/her final
  destination.
• Five stages are precontemplation, contemplation,
  preparation, action, and maintenance

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Theoretical Basis for the 5As

• The 5 Stages of Change
• The first 3 stages are indicative of readiness to
  change.
• Patients will use specific behaviors with certain
  stages.
• Last 2 stages represent action (i.e. quitting,
  abstaining, drying out, cold turkey)

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Applying the TTM Modelto Tobacco Addiction

• 5 As of tobacco cessation treatment
• Ask
• Advise
• Assess
• Assist
• Arrange

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5 As Ask

• Ask about smokingsome questions are better than
  others.
• Do you smoke now? is okay but social
  desirability is an issue with prenatal smokers
• Robert Wood Johnsons Smoke Free Families
  initiative suggest the following

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5 As Ask

• Which of the following statements best describes
  your cigarette smoking?
• I have never smoked or have smoked fewer than 100
  cigarettes in my life.
• 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 I am not smoking now.
• I smoke some now but have cut down since I found
  out I was pregnant.
• I smoke about the same amount now as I did before
  I found out I was pregnant.

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5 As Advise

• Be clear, Be strong, and make it personal
• Clear Its important that you quit smoking as
  soon as possible.
• Strong Quitting smoking is the most important
  thing you can do to protect your health.
• Personal I know that quitting smoking is hard.
  I am here to help you. When you are ready, I
  will work with you to be successful.

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5 As Assess

• Assessing a persons readiness to quit smoking
• The decision to quit lies in the hands of each
  patient.
• Patients differ in their readiness to commit to
  quitting.
• Your actions will be based upon the patients
  readiness to make a change.

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Is the Patient Ready to Quit?

• Does the patient now use tobacco?
• Yes No
• Is the patient now Did the patient
• ready to quit? once use
  tobacco?
• No Yes Yes
  No
• Promote provide prevent Encourage
• motivation treatment relapse abstinence

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Is the Patient Ready to Quit?

• Does the patient now use tobacco?
• Yes No
• Is the patient now Did the patient
• ready to quit? once use
  tobacco?
• No Yes Yes
  No
• Precontemplation preparation action
• contemplation or maintenance

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Patient Not Thinking AboutQuitting

• Do
• Strongly advise to quit
• Raise awareness of health concerns
• Demonstrate empathy, foster communication
• Leave decision to patient

• Donts
• Persuade
• Cheerlead
• Tell patients how bad smoking is an a judgmental
  manner

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5As Advise

• Many pregnant women are tempted to cut down
  the number of cigarettes they smoke instead of
  quitting.
• Cutting down to less than 5 cigarettes a day
  can reduce risk, but quitting is the best thing
  you can do for you and your baby.

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5As Advise

• Its never too late to quit smoking during
  your pregnancy. After just one day of not
  smoking, your baby will get more oxygen.
• Each day that you dont smoke, you are
  helping your baby grow.

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5As Advise

• During the first few weeks after quitting,
  cravings and withdrawal symptoms may be
  strongest.
• You can reduce the length of each craving for
  a cigarette by distracting yourself (keep your
  hands, mouth, and mind busy).

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5As Advise

• Withdrawal symptoms are often signs that your
  body is healing. They are normal, temporary, and
  will lessen in a couple of weeks.

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5As Advise

• Weight gain during pregnancy is normal. If you
  are worried about gaining weight when you quit
  smoking, now is an ideal time to quit.
• The weight you gain is far less harmful than
  the risk you take by smoking.

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5 As Assist

• Suggest and encourage the use of problem-solving
  methods and skills for tobacco cessation.
• Provide social support as part of the treatment.
• Arrange social support in the smokers
  environment.
• Provide pregnancy-specific self-help smoking
  cessation materials.

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5 As Assist

• Know your reasons for quitting.
• Change your daily habits.
• Keep your hands and mouth busy.
• Deal with negative emotions.
• Cope with withdrawal.
• Handle others smoking around you.
• Find support for your quitting.

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5 As Assist

• If you smoke when you Try doing this
• Drink coffee Have hot chocolate or herbal
  tea
• Finish a meal Get right up,
  take a walk, or go into another room
• Watch TV Do something
  else with your hands (start a craft)
  and mouth (chew gum eat a hard candy)

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5 As Assist

• Examples of ways to keep your hands and mouth
  busyYour hands Your mouthKnit or
  sew Chew gum
• Play with a rubber band Eat some fresh fruit
• Hold a pencil or pen Use a straw or
  toothpick
• Draw or doodle Suck on hard candy
• Squeeze a rubber ball Try a cinnamon
  stick
• Work on a craft project sip water or juice

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5 As Assist

• If you smoke when you feel
• Stressed or nervous...
• Bored or lonely...
• Angry or upset...

• Try doing this
• Go for a walk take a hard candy break remind
  yourself what you do well
• Talk to a friend plan a baby project do
  something you enjoy listen to music
• Write down your feelings take a walk talk to a
  friend

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5 As Assist

• Ask the friend or family member to quit with
  you.
• Ask others not to smoke around you, now that
  youre pregnant.
• Make your home and car non-smoking areas.
• Leave the room when others light a cigarette.
• Plan ways to distract yourself when someone else
  is smoking. Keep your hands and mouth busy.

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5 As Arrange

• Follow up to monitor her progress with smoking
  cessation
• Provide and identify support
• Identify any high risk situations
• Counsel the patient about potential relapse
• Talk about her success

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5 As Arrange
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5 As Arrange

• Options will vary according to what patient is
  interested in
• Referral Sources
• KDHE Tobacco Use and Prevention Program
• Kansas Quitline (1-866-KAN-STOP)
• (1-866-526-7867)

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When You Are Stuck!

• The 5 Rs
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

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5 Rs Relevance

• Has the patient smoked before in previous
  pregnancies?
• Does she have friends/family members who smoked
  in their pregnancies?
• What does her family think about her not smoking?
• Does she believe in the harm caused by smoking to
  her baby?

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5 Rs Risks

• Previous miscarriage
• Infertility problems
• Potential harm to infant with continued smoking
• Potential harm to the patient during pregnancy

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5 Rs Rewards

• Better health for the baby
• Home, clothes, hair, car all smell better
• Save money by not smoking
• Over time you will have more energy

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5 Rs Roadblocks

• Being around other smokers
• Handling negative moods during pregnancy
• Dealing with temptations, cravings, and
  withdrawal during pregnancy
• What does she see as the biggest problem to her
  quitting smoking

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5 Rs Repetition

• Use each prenatal visit to inquire about
  patients smoking status
• All providers should be consistent with their not
  smoking message no mixed messages

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Case Studies

• Mary is a 18 year old G1 P0 patient at your
  prenatal clinic. Her LMP would suggest she is
  12 weeks along in her pregnancy. She is
  currently single, applying for Medicaid coverage
  of her pregnancy, and is employed part-time at
  the local grocery store.

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Case Studies

• Bobbie is a 22 year old female who presents
  to the family planning clinic with signs/symptoms
  of pregnancy. A urine B HCG test confirms her
  suspicions. You can smell tobacco smoke on her
  breath and on her clothes.

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Case Studies

• Susie is a 33 year old G3 P2 female who
  presents to the prenatal clinic at 22 weeks
  gestation. When asked if she smokes she answers
  yes and goes on to say I smoked in my first 2
  pregnancies and the babies turned out fine.

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Break Time!!