Treating Tobacco Use and Dependence Among Your Pregnant Clients

1
Treating Tobacco Use and Dependence Among Your
Pregnant Clients
2
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.

Lung Cancer Fact Sheet, American Lung
Association 2006
3
Tobacco Use during Pregnancy

• Smoking remains the single most important
  preventable cause of poor birth outcomes
• 20 low birth weight deliveries
• 8 pre-term births
• 5 perinatal deaths

4
How Tobacco Use in Pregnancy Harms the Infant

• Causal association
• -abruptio placenta
• -small for gestational age
• -preterm delivery
• -Sudden Infant Death Syndrome (SIDS)
• -stillbirth

5
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

6
Benefits for the Baby

• Increases the amount of oxygen the baby will get
• Increases the chances the babys lungs will work
  well
• Lowers the risk that the baby will be born too
  early
• Increases the chances of having a normal weight
  baby
• Increases the chances the baby will come home
  from the hospital with the mother

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Facts about Quitting during Pregnancy

• Many women are tempted to cut down and while
  cutting down may help, the best thing she can do
  for herself and her baby is to quit.
• Its never too late to quit during your pregnancy
• After just one day of not smoking, the baby will
  get more oxygen. Each day that the mother doesnt
  smoke helps the baby grow.

8
Pregnancy is an Opportune Time to Treat

• Social good associated with intervening during
  pregnancy is widely supported
• Systems supports are being developed
• Pregnancy as a unique teachable moment for women,
  partners and others
• Strong provider support
• Compelling health and cost benefits

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Missed Opportunitiesin Pregnancy By Not Asking
National Ambulatory Medical Care Survey, 1995
Thorndike, et al, 1998 JAMA 279604-8 1991 JNCI
911957-62
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Recommended Multiple-Choice Question

• Which of the following statements best describes
  your cigarette smoking? Would you say
• 1. I smoke regularly now -- about the same amount
  as before finding out I was pregnant.
• 2. I smoke regularly now, but Ive cut down since
  I found out I was pregnant.
• 3. I smoke every once in a while.
• 4. I have quit smoking since finding out I was
  pregnant.
• 5. I wasnt smoking around the time I found out I
  was pregnant, and I dont currently smoke
  cigarettes.

Mullen et al., 1991
Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
11
Classification of Responses

• Womens tobacco use can be classified into 3
  groups based on their responses
• Current smoker
• Former smoker
• Never smoked

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
12
For the Woman Who Has Never Smoked

• Acknowledge that she has made a good decision not
  to smoke
• Move on to other topics related to her pregnancy

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
13
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

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
14
For Pregnant Women Continuing to Smoke

• ?Advise
• ?Assess
• ?Assist
• ?Arrange

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
15
ADVISE

• Provide clear, strong advice
• to quit with personalized messages about the
  impact of smoking and quitting on the woman and
  fetus.

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
16
ASSESS

• Assess the willingness of the patient to attempt
  to quit within the next two to four weeks
• If the patient is ready to quit, proceed to
  ASSIST.
• If the patient is not ready, provide information
  to motivate the patient to quit and proceed to
  ARRANGE.

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ASSIST

• Refer patients to the NYS Quitline at
• 1-866-NYQUITS (1-866-697-8487) for cessation
  counseling and information.
• Use the fax-to-quit program.
• Inform patients about pharmacotherapy options
  (free to Medicaid patients).

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New York StateSmokers Quitline

• Free and confidential program that provides
  evidence based stop smoking services.
• New York residents only call1-866-NY QUITS
• (1-866-697-8487)
• Callers may speak to trained specialists
• Mon. Fri 9am-9pm. 9am-100pm Sat - Sun.
• Deaf or hearing impaired call TTY 1-800-280-1213
• Bi-lingual
• Website www.nysmokefree.com

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Fax-To-Quit Program

• Health care providers can confidentially refer
  their tobacco-using patients to the NYS Smokers
  Quitline using the Fax-To-Quit referral form.
• Patients will receive a follow-up call from a
  Quit-Coach who will provide a stop smoking or
  stop smokeless-tobacco counseling session.
• Patients will receive a Stop Smoking or Stop
  Smokeless Tobacco packet in the mail with
  information tailored to their specific situation
  and a listing of local stop smoking programs.

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Skills Example Handling Others Smoking Around You

• Consider these ways to handle the situation
• Ask a 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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Adjuncts to the 5 As

• Referral to more intensive counseling to achieve
  cessation should be considered for women who
  continue to smoke.
• The use of pharmacotherapies should be considered
  only for heavy smokers and if behavioral
  interventions have not yielded a quit.
• The efficacy and safety of pharmacotherapies
  during pregnancy is unknown.

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
22
Rewards (ask patient to identify first)

• Can stop worrying about quitting.
• Set a good example for children.
• Have healthier babies and children.
• Not worry about exposing baby others to smoke.
• Feel better in physical activities.

• Improved health.
• Food will taste better.
• Improved sense of smell.
• Save money.
• Feel better about yourself.
• Home, car, clothing, breath will smell better.
• Reduced wrinkling/aging of skin.

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Arrange

• Assess smoking status at subsequent visits and,
  if the patient continues to smoke, encourage
  cessation.
• If the patient remains smoke-free, give praise.

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000
24

• Minimal intervention lasting less than three
  minutes increases overall tobacco abstinence
  rates.
• -

Treating Tobacco Use and Dependency Clinical
Practice Guideline US Public Health Service 2000