Smoking in Pregnancy

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Smoking in Pregnancy

• Dr Philippa Marsden
• Consultant Obstetrician and Gynaecologist

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Smoking and Pregnancy

• Introduction important group to target
• Effect of smoking on pregnancy
• Scale of the problem
• High Impact actions
• Challenges
• Pregnancy quitters case studies

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Introduction Important Group to Target

• Health issues
• Numerous opportunities to help smokers to quit
• Greater contact with healthcare systems
• Women more motivated at this time
• Peer pressure from friends and family to quit
• Women experience higher levels of family support
  to stop smoking

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Risks of Smoking in Pregnancy
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Risks to Fetus
Fetal anomalies
Growth restriction Low birth weight
Teratogenicity
Placental abruption
Fetal Hypoxia
Premature delivery
Fetal distress
Stillbirth
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Risks to Mother

• Reproductive function
• Fertility
• Miscarriage
• Ectopic pregnancy
• Obstetric complications
• Maternal morbidity/mortality

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Risk to Mother - Mortality

• CEMACH
• Triennial report since 1952
• Maternal mortality
• While pregnant or within 42 days of end of
  pregnancy
• Direct / Indirect deaths
• Late deaths

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Risk to Mother

• 1952 1954 1403 direct deaths
• 2003 2005 106 direct deaths
• Improvement in health care
• Treatment of sepsis, blood transfusion, safety of
  anaesthesia etc
• But concern that maternal mortality has not
  deceased in recent years
• The women that died were in poorer health,
  smoked more and were overweight or obese

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Risks to Mother - Mortality
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Risk to Mother

• 16 deaths from cardiac causes
• Most common cause of indirect deaths as well as
  of maternal deaths overall
• Reflects the younger incidence of acquired heart
  disease in younger women related to less healthy
  diets, smoking, and growing epidemic of obesity

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Risks to Child

• SIDS
• Acute respiratory infections
• Ear problems
• Asthma

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Scale of the Problem

• Incidence in the northeast
• Smoking prevalence 35 age 20-34
• Higher in the north east - rising
• Younger mothers as high as 45
• 73 quit before their first antenatal visit
• Groups at risk less likely to quit
• Health inequalities
• Socially disadvantaged
• Teenagers
• Healthcare costs - 66 higher than non-smoker

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High Impact Actions
Regional Summit October 2007 to raise
awareness of health implications of smoking and
maternal and child health Outcome Production of
a regional action plan based on the Dept of
Healths - Integrating high impact actions into
routine health care practice
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High Impact Action 1

• Promoting cessation to women of child bearing age
• Promoting smoking cessation pre-pregnancy one
  of the most effective interventions in reducing
  smoking rates during pregnancy
• Offers best protection for infant increases
  womans intrinsic motivation to quit for own
  health
• Target primary care, family planning clinics,
  chemists, infertility clinics, schools etc
• Focus on mother, baby and whole family promote
  smokefree
• Training needed

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High Impact Action 2

• Improving data collection
• Difficult to identify pregnant smokers and
  spontaneous quitters deception rates vary from
  3 50
• Consider multiple choice questionnaire improves
  disclosure rates
• Carbon monoxide testing to facilitate identifying
  smokers and provide support/encouragement
• Need clear clinic/office systems
  institutionalising identification and
  intervention protocols reminding everyone who
  comes into contact with pre-conception, pregnant
  and postpartum women to discuss smoking

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Multiple Choice Questionnaire
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High Impact Action 3

• Reaching pregnancy smokers as soon as possible
  and throughout pregnancy
• Gov priority (2010) to reduce health inequalities
  to reduce by infant mortality and life
  expectancy at birth by 10
• Infant MR for babies lt 1500g x 104 x 2
• Infant MR for babies lt 2500g x 22 in
  smokers
• Need to identify all pregnant smokers and
  remember spontaneous quitters sensitivity and
  tact needed
• Give accurate information dispel myths
• Training needed to empower women to make own
  decisions

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High Impact Action 4

• Increasing effectiveness of current interventions
• Brief counselling interventions combined with
  pregnancy specific resources cessation rate by
  30 70 in light to moderate smokers little
  impact on heavily addicted
• Nicotine replacement for those unable to quit
  with behavioural support

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Brief Cessation Counselling
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High Impact Action 5

• Supporting continuing smokers
• 1 in 5 women continue to smoke but most reduce
  the amount
• Low se groups with multiple and complex lifestyle
  problems
• Practitioners advice needs to focus
  unequivocally on stopping but strategies to
  reduce smoking may be acceptable in certain
  situations
• Continue imput with women adamant they will not
  stop - Stress adverse effects on birthweight in
  2nd and 3rd trimesters, abstinence during birth,
  healthy eating, physical activity, promoting
  smokefree

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High Impact Action 6

• Involving partners and families
• 2/3 of partners smoke Critical factor
• Only ¼ of men make any change to smoking
  behaviour
• only 1 in 20 give up smoking
• Smoking partner - Most influential single
  facilitator to return to smoking
• Need to involve partners in helping pregnant
  women to stop and stay stopped postpartum
• Promoting Smokefree

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High Impact Action 7

• Maintaining postpartum cessation
• Many women view themselves as suspended smokers
  - 80 of women who quit smoking because of
  pregnancy start smoking again within a year
• During pregnancy important to highlight the
  benefits of quitting for the mothers and child's
  health after delivery as well as the unborn child
• Smokefree homes prolong time to relapse

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High Impact Action 8

• Promoting smokefree families
• Risks no safe level of exposure
• Smokers in total SF household were 4 X more
  likely to quit
• Smokefree increases the chance of quitting in
  young people
• Smokefree can discourage smoking initiation
• Focussing on restricting or eliminating smoking
  in the home - Non-confrontational approach to
  bring up smoking with pregnant smokers

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Challenges

• Unplanned pregnancies - ?
• Difficult messages in happy clinic setting
• Miscarriage, stillbirth, cot death
• Prematurity, complicated delivery - CS
• Not about your own comfort/feelings
• Resources
• High risk pregnancy but
• Not Consultant booking
• No growth scans
• No monitoring until a problem develops
• Training

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Summary

• Important group to target
• Smoking seriously affects maternal and child
  health high risk group
• Every health professional has a duty to get the
  message across
• Training and resources an issue
• True figures/Research important

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Thankyou
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Reducing Health Inequalities in County Durham
Darlington Engaging in Effective Tobacco Control