Transcript SMOKING CESSATION
Smoking Cessation in Pregnancy
Richard O. Davis, MD Department of OB/GYN
Division Maternal Fetal Medicine University of Alabama at Birmingham
Objectives
Discuss the adverse outcomes related to smoking in general Discuss the adverse outcomes related to smoking during pregnancy Discuss benefits of smoking cessation during pregnancy Discuss methods to achieve smoking cessation during pregnancy Discuss relapse rates and potential avenues of decreasing relapse
The Culprit
“Nicotina Tobacum” “Discovered” by Columbus on trips to New World - Became widely popular in western Europe - Initially popular in snuff and cigars - Manufactured cigarette in 20 th Century increased smoking
The Facts Tobacco Related Disease (TRD)
21% of American adults smoke (44.5 million)
Each year, 440,000 Americans die of TRD
Accounts for 1 in every 5 deaths
Ann Int Medicine 2006;145:839-44
The Facts Smoking
Increased cardiovascular disease
Increased lung cancer
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68,000 women die annually
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Responsible for 1 in 4 cancer deaths in women
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27,000 more deaths each year than breast cancer Public Health Service, Office of Surgeon General 2001
The Facts Initiation of Smoking
Begins early during teenage years
22% of U.S. high school students smoke
Historically, male smoking rates greater than female
In many countries, no sex difference in smoking rates Lancet 2006;367:749-53
Women Who Smoke
High parity
Lesser education
Low economic status
Poor coping skills
Exposure to domestic violence
Job strain
Cultural Influence Women Who Smoke
Native American/Alaskan White (Non-Hispanic) Black (Non-Hispanic) Other Asian 29% 20% 17% 18% 5% MMWR 2004;53:427-51
The Facts Complications in Pregnancy
Increased risk of ectopic pregnancy
Placenta previa
Placenta abruption
Stillbirth
Premature rupture of membranes Clin Obstet Gynecol 2008;51(2):419-35
Complications in Pregnancy The Likely Culprits
Nicotine: vasoconstriction
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Fetal serum (15%) and amniotic fluid levels (88%) higher than maternal
Carbon Monoxide: Diminished tissue oxygenation
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Fetal levels higher (15%) than maternal
Cyanide: Harmful to rapidly dividing cells
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Cyanide levels are higher in smokers Clin Obstet Gynecol 2008;51(2):419-35
Complications in Pregnancy Other Toxic Compounds
Ammonia
Polycyclic aromatic hydrocarbons
Vinyl chloride
Nitrogen oxide
Complications in Pregnancy (Heavy Smoking > 20 cigarettes/day)
Low birthweight (<2500 g) (
200-300 g)
Preterm birth (OR 1.2 – 1.8)
Smoking accounts for 5% of prenatal deaths and 20-30% of low birthweight deliveries Clin Obstet Gynecol 2008;51(2):419-35
Maternal Life Time Smoking Complications
Atherosclerotic disease
Lung cancer
COPD
Increased risk of ectopic pregnancy
Premature menopause
Infertility
Osteoporosis
Infants, Children and Secondhand Smoke Increased Risks
Respiratory infections
SIDS
Asthma/bronchitis
Short stature
Hyperactivity
Decreased school performance Clin Obstet Gynecol 2008;51(2):419-35
Smoking Cessation Interventions
Higher proportion of women stop during pregnancy than at any other time in their lives
20-30% of smoking women attempt to stop
About 40% who stop do so before their first OB visit
Factors: Concern for effects on baby; nausea and vomiting Cochrane Database Sys Rev 2005
Challenges and Barriers to Cessation
Need to be acknowledged by patient and provider
Most smokers make several attempts to quit
Discuss reasons for past failures
Successful smoking cessation is associated with continuous patient education and assessment
The 5 A’s and 5 R’s (endorsed by ACOG and National Cancer Institute and British Thoracic Society) for patients unable or reluctant to quit Clin Obstet Gynecol 2008;51(2):419-35
The 5 A’s
Ask: Query with multiple choice questions, document
Advise: Urge tobacco users to quit
Assess: Determine willingness to quit
Assist: Provide aid and choose quit date
Arrange: Provide follow-up contact. Congratulate success. Consider referral or more intensive treatment and potential pharmacotherapy
The 5 R’s
Relevance: Identify motivational factors
Risk: Stress the acute and long-term risks of smoking
Reward: Ask/Help patient identify benefits to her and her family
Road blocks: Identify barriers and impediments
Repetition: Repeat motivational intervention and visit
Smoking Cessation Intervention Why During Pregnancy?
Genuine concern for baby
Frequent physician/provider visits
Only time some women seek medical care
Likely to experience high levels of social and family support for quitting
Smoking Cessation Programs
Shown to be helpful compared with no intervention
Tobacco dependence treatments are clinically useful and cost effective Cochrane Database Sys Rev 2005 JAMA 2000;283:3244-254
Successful Smoking Cessation
Prevent up to 5% of perinatal deaths
Prevent up to 20-30% of low birthweight births
Prevent up to 15% of preterm births Am J Obstet Gynecol 2005;192:1856-1862
Smoking Cessation in Pregnancy
Smoking has greatest impact in third trimester
Encourage smoking cessation throughout pregnancy
Women who quit by third trimester have birthweights similar to non-smokers Am J Public Health 1994;84:1127
Role of Counseling Meta Analysis
Brief, intense counseling 5-15 minutes
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Cessation rate 5%-10%
Brief counseling and pregnancy specific educational printed material
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Cessation doubles to about 20%
Cost Effectiveness of Smoking Cessation
For every $1 for successful cessation, $3.3 are saved on treating shorten neonatal morbidities (NICU)
Ratio of savings increase to 6:1 when long-term care and morbidity are considered
Until further evidence based conclusions are made, brief cognitive behavioral interventions accompanied by pregnancy-specific self-help materials are most effective intervention for pregnant smokers.
Individual Counseling for Smoking Cessation Cochrane Database Sys Rev 2005
Nicotine Replacement Therapy
RCT by Wisborg
et al
showed that nicotine patches did not affect cessation rate, but did increase BW
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Under-powered Low compliance
RCT by Oncken
et al
demonstrated that nicotine gum had no effect on cessation rate
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Significantly reduced smoking Increased EGA and BW at delivery
Pollak
et al
showed NRT increased cessation rate by 3 fold, but there was increased adverse outcomes in this group
Wisborg
et al
. 2000. Obstet Gynecol 96:967-971.
Oncken
et al
. 2009. Obstet Gynecol 112:859-867.
Pollack
et al
. 2007. Am J Prev Med 33:297-305 .
Bupropion
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Aminoketone that is a weak reuptake inhibitor of dopamine, norepinephrine, and serotonin initially utilized as an antidepressant
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In non-pregnant adults, multiple studies have shown that bupropion significantly improves smoking cessation rates
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Case-control study including ~6K in each group by Alwan
et al
showed infants with cardiac defects were more likely to have been exposed to bupropion than controls (AOR 2.6; 95% CI 1.2 5.7)
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3 other studies showed no association
Alwan
et al
Hurt
et al
1997. NEJM 337:1195-1202 2010. Am J Obstet Gynecol 203:52e.1-6.
Chun-Fai-Chan B
et al
2005. Am J Obstet Gynecol 192:932-6 .
U.S. Department of Health and Human Services Clinical Guidelines 2008
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Pregnant women should be actively counseled and provided information regarding benefits of smoking cessation
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Smoking cessation in early pregnancy is preferred, but cessation at any time is beneficial
U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) Treating Tobacco Use and Dependence: 2008 Update
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No recommendation regarding medication use during pregnancy
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NRT is probably safer than nicotine exposure from cigarettes
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Inconclusive evidence that cessation medications boost abstinence rates in pregnant smokers
Postpartum Period and Relapse
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50%-90% relapse within first year after delivery
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No proven strategies to prevent relapse
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Continue encouragement, enforce benefits of cessation, reinforce patient’s desire to be a good mother