Download Smoking cessation during pregnancy and lactation

Alice Ordean MD, CCFP, MHSc
Medical Director, T-CUP, SJHC
November 30, 2011





Prevalence of tobacco use during pregnancy
Effects: obstetrical, fetal, neonatal,
adolescence
Screening and assessment for nicotine
dependence
Smoking cessation interventions during
pregnancy
Tools and resources





22% of women report smoking in the 3 months prior to
pregnancy or before becoming aware of pregnancy (16%
smoking daily, 6% occasionally)
Proportion of women who smoked during pregnancy
declined to ~11% in third trimester (7% smoked daily &
4% occasionally)
Proportion of daily smokers who smoked 10+ cig/day
declined during pregnancy & increased again
postpartum
Daily smokers in T3: 58% smoked 1-9 cig/day, 42%
smoked >10 cig
80% of women try to quit or reduce smoking
Ref: Canadian Maternity Experiences Survey, 2009



47% of those who quit during pregnancy had
resumed smoking by 6 months postpartum –
overall 16% were smoking after delivery (12%
daily, 4% occasionally)
During pregnancy, 23% of women lived with
someone who smoked
Reasons for smoking postpartum: stress
mgmt, time for herself, losing weight




Younger age: <24 years old
Educational level: less than high school
education
Multiparity
Low socioeconomic status: Women living in a
household at or below the low income cut-off

Marital status: single mothers

Variations by provinces & territories
Ref: Canadian Maternity Experiences Survey, 2009
Dose-response relationship documented: effects
influenced by amount & duration of smoking
Increased risk of :





Spontaneous abortion -1.5x, ectopic pregnancy
Intrauterine growth restriction (IUGR) – 2x
Preterm delivery, premature rupture of membranes
Placental complications (placenta previa, placental
abruption) 2x
Infant morbidity & mortality (eg. stillbirth) mostly
due to increased IUGR and preterm delivery
Ref: www.pregnets.org




Products of tobacco smoke are concentrated in
breast milk (up to 5x greater than in blood)
Smoking can decrease quality & quantity of
breast milk by inhibiting milk let-down 
feeding difficulties and early weaning from BF
Breastfeeding is protective against respiratory
illnesses  BF is encouraged among smokers
Nicotine levels increase after smoking; half-life
of nicotine is 95 minutes  women should
avoid smoking just before and during feeding
Effects linked to maternal smoking during pregnancy
and second-hand smoke exposure
Increased risk of:






More cranky or colicky babies
Sudden infant death syndrome 2-5x
Respiratory illnesses eg. bronchitis, pneumonia
Asthma & allergies up to 400x
Middle ear infections
Neurodevelopmental (eg. poorer math & reading
skills) & behavioural problems (eg. attentiondeficit/hyperactivity disorder)
Pregnancy Complications
Subfertility (female and
male)
Ectopic pregnancy (outside
the uterus)
Spontaneous abortion
(miscarriage)
Preterm labour
Premature rupture of
membranes
Placental problems (previa
& abruption)
Growth restriction
Neonatal
Effects
Long-Term
Effects
Low birth weight (on
average ~200 grams smaller)
Increased perinatal mortality
Increased admission to the
neonatal intensive care unit
(NICU)
Sudden infant death
syndrome (SIDS)
Decreased volume of breast
milk and duration of
breastfeeding
Childhood respiratory
illnesses (asthma, pneumonia,
bronchitis)
Other childhood medical
problems (ear infections)
Learning problems (reading,
mathematics, general ability)
Behavioral problems
Attention deficit
hyperactivity disorder
(ADHD)
[1] Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2005


Cigarette smoking during pregnancy and
breastfeeding is associated with numerous
negative effects – preventable outcomes by
cessation of smoking at any point during
pregnancy
Pregnancy represents a window of
opportunity to help woman make a change
Women with the following characteristics are
more likely to quit smoking:





higher educated
lighter smokers
those who live with nonsmokers
those with stronger beliefs in the harms of
smoking
those experiencing their first pregnancy
1.
2.
3.
Woman-centred care: care focused on woman’s
needs in context of social, economic life
circumstances eg. Focus on woman’s health
before and during pregnancy
Harm reduction: focus on reducing harm to
woman & fetus from effects of smoking eg.
Reduced smoking, nicotine replacement tx
Reducing stigma to help engage pregnant
smokers: deal with pressures to quit smoking




Offer a variety of cessation approaches and
intensities depending on stage of change
Address the postpartum period in the
prenatal intervention
Build-in partner support
Encourage smoking reduction as an
alternative to smoking cessation for those
unable to quit
ASK: “Do you smoke? How many cigarettes do
you smoke?”

If she does not smoke, inquire about
environmental tobacco exposure
“Does anyone smoke around you or your
children?”

If yes, then educate about ways to stop or
decrease exposure to second hand smoke
Assess motivation/readiness to change
behaviour




Ask: “How do you feel about your smoking?
Are you planning to quit?”
“On a scale of 1-10 how would you rate your
motivation to quit smoking at this time?
“On a scale of 1-10, how important is it for you to
quit at this time?”
“On a scale of 1-10, how confident are you that
you can quit smoking at this time?”
Precontemplation
Contemplation
Relapse
Preparation
Action
Maintenance
16
Pre-contemplative: no interest in quitting, or
“in more than 6 months”
Contemplative: thinking about quitting in 1-6
months
Preparation: planning to quit in next month
Action stage: in process of cutting down or has
set a quit date
Maintenance: quit more than 6 months ago





Amount & duration smoked (pack-years),
pattern of smoking
Degree of dependence eg. Fagerstrom test –
time from waking up to first cigarette
Reasons for smoking and for quitting
Past experience with quitting: what worked
and what did not, relapse triggers
Other addictions, medical problems,
psychiatric problems, medications
1. Counselling: tailor intervention according to
stage of change & focus on moving patients
along stages of change and enhancing
confidence to quit
2. Pharmacotherapy: suppress withdrawal
symptoms & cravings



Nicotine replacement therapies
Bupropion (Zyban)
Varenicline (Champix)



Smoking cessation should be encouraged for
all pregnant, breastfeeding and postpartum
women
A smoke-free home environment should also
be encouraged to avoid exposure to secondhand smoke
Counselling is recommended as first line
treatment for smoking cessation during
pregnancy and breastfeeding (some evidence
for increased quitting rates)
Stage of change
Intervention
Pre-contemplative
Initiate discussion about impact of
smoking on patient’s life,
encourage smoke free house/car &
provide educational materials
Contemplative
Increase motivation to quit: offer
help, complete decisional balance
– pros & cons of smoking and
quitting
Preparation
Help find right treatment: plan for
quitting eg. past quit hx, barriers
& smoking triggers, set quit date
Action
Support & sustain cessation
efforts: coping strategies ,
medications, follow-up visits
Maintenance
Relapse prevention counselling
• Counselling: brief, delivered by range of
practitioners; may be conducted by physicians,
allied healthcare professionals (e.g. social worker,
pharmacist), family home visitors, etc.
• Quit guides: take-home, patient-focused guide to
quitting
• Buddy support: to provide social support
• Partner counselling/social context
• Education about pregnancy & smoking
During Pregnancy
 Make no-smoking rules for her home

Handling the challenge of partner smoking

Avoid triggers & remove “reminders”
Postpartum
 Explain to others that the same no-smoking
rules apply as in pregnancy

Be aware of what’s happening: discuss what
she enjoyed about smoking vs. non-smoking

Be prepared to resist it: change past routines

Remember that it will not last long


Use a non-smoking alternative whenever feel
the need to smoke eg. exercising, chewing
gum, eating, using relaxation skills & other
enjoyable activities eg. phoning a friend
Avoid other substances eg. coffee, alcohol



Assure patient that slips and relapses are
normal: learning opportunity, not a failure
Identify triggers & develop a plan to cope
with them
Maintain motivation and encourage positive
self-talk to maintain self-confidence

Strengthen commitment

Get back on track



Partners, friends & family members should also
be offered smoking cessation interventions
Despite preliminary evidence that continued
smoking and relapse are more likely among
pregnant women who have a smoking partner,
there is limited data regarding the benefits of
partner involvement in smoking cessation
interventions for pregnant smokers
In non-pregnant populations, interventions to
increase support did not find increased quitting
rates
Second-line treatment options during
pregnancy may include:



Nicotine replacement therapies
Bupropion (Zyban)
Varenicline (Champix)




Symptoms increase by 3-4 days after quitting
smoking and last for 1 week
First symptoms: dysphoric or depressed
mood, irritability, restlessness, anxiety,
insomnia, fatigue, increased appetite
Lack of concentration and cravings may last
for months
Symptoms worse in heavy smokers and those
who smoke within 30 minutes of getting up



NRT can be considered as a second line
option for individuals who cannot quit after
counselling interventions
Intermittent dosing nicotine replacement
therapies (such as lozenges/gum) are
preferred over continuous dosing of a patch
There is limited evidence on harms
associated with the use of nicotine
replacement therapy (NRT) during pregnancy


Evidence from RCTs failed to find a difference
in smoking cessation rates, but there may be
some decrease in number of cigarettes
smoked per day & improved pregnancy
outcomes (lower rates of preterm delivery &
low birth weight)
Benefits of NRT seems to outweigh potential
risks; therefore, NRT should be considered
when counselling has been ineffective.


Depression during pregnancy is a common
occurrence and the use of Zyban (bupropion)
may be appropriate to treat both smoking
and depression
There is limited evidence on the effectiveness
of bupropion for smoking cessation during
pregnancy; only 1 prospective study
demonstrated increased quitting rates with
bupropion use during pregnancy

In addition, there is no evidence of harm
related to the use of bupropion during
pregnancy and therefore, it may be
considered for use as an alternative to NRT
for a subpopulation of pregnant smokers.

No evidence regarding safety of varenicline
during pregnancy; therefore, its use during
pregnancy is not recommended.
ASK
Smoker
ADVISE to quit or
reduce smoking
ARRANGE follow-up
Non-smoker
ASSIST by providing
brief interventions or
making referral
ASK about secondhand smoke
exposure



PREGNETS www.pregnets.org [specialized
toolkit to address smoking cessation among
pregnant & postpartum women]
CAN-ADAPTT www.can-adaptt.net [evidencebased clinical practice guidelines]
TEACH (Training enhancement in applied
cessation counselling and health)“Helping
Pregnant Smokers Stop Smoking: An
Interactive Case Based Course [evidencebased training and continuing professional
education]



CAMH Nicotine Dependence Clinic
www.camh.net
Ontario Smokers Helpline 1-877-513-5333
Motherisk www.motherisk.org or 1-877327-4636



Clinical practice guideline &
knowledge exchange
network
Integrates practice, policy
and research in a
collaborative smoking
cessation network
Goal: To inform the
development of a PanCanadian clinical practice
guideline (CPG) for
smoking cessation
Dr. Peter Selby, Principal Investigator, CAN-ADAPTT
Funded by the Drugs and Tobacco Initiatives Program, Health Canada





Smoking cessation should be encouraged to all pregnant and
breastfeeding women. (GRADE = 1A)
During pregnancy and breastfeeding, counselling is
recommended as first line treatment for smoking
cessation. (GRADE = 1A)
If counselling is found ineffective, intermittent dosing
nicotine replacement therapies (such as lozenges, gum) are
preferred over continuous dosing of the patch after a riskbenefit analysis. (GRADE = 1C)
Partners, friends and family members should also be offered
smoking cessation interventions. (GRADE = 2B)
A smoke-free home environment should be encouraged for
pregnant and breastfeeding women to avoid exposure to
second-hand smoke. (GRADE: 1B)
Durham Region Health Department provides a
number of services to promote and support
tobacco-free living
DRHD offers:
• A 6-week Support Group for smokers that want to quit using tobacco
• Telephone counselling
• Quit Kits for prenatal and postpartum women that contain self-help materials
• Information for new dads regarding quitting smoking and second-hand smoke
• Assistance for health care providers to develop comprehensive tobacco
cessation strategies for their setting
• Information and resources regarding community supports available to facilitate
tobacco cessation
Contact Durham Health Connection Line 905-666-6241 or 1-800-841-2729
Health Unit Actions:



Knowledge & skill training for all Chronic Disease & Family
Health Department Staff
Implement 4A protocols
◦ Information Request Line
◦ Prenatal Programs
◦ Healthy Babies Healthy Children
◦ Post-partum Enhancement Program
◦ Integrated into continuum of care for follow-up (family
home visitors & family health nurses)
Focus on increasing access to cessation services by
developing community capacity to provide brief
interventions in a variety of settings
Partners with local health care professionals
to:




Provide training & technical assistance to
develop community capacity to provide
interventions
Increase awareness of evidence-based
cessation initiatives
Motivate local practitioners to implement
evidence-based strategies (eg. 4A Protocol)
Increase the number of people
contemplating, preparing & taking action to
quit (particularly among youth, young men,
& people with low SES)




One to one individual
counselling
appointments
Quit smoking groups
Telephone counselling
Provision of self-help
resources
Funded by Health Canada to March
2012





Support group for pregnant
and post partum women
who smoke
Facilitated by a Community
Health Worker and Public
Health Nurse
Free Childcare
Free transportation
$20 Gift card every week
Funded by ECHO: Improving Women’s
Health In Ontario to March 2013

Free, confidential phone, online and text messaging services
at 1 877 513-5333 and SmokersHelpline.ca

English, French and interpreter service

Accept Fax Referrals from health care providers through Quit
Connection program (www.smokershelpline.ca/refer)

Specialized protocols in place to serve pregnant and postpartum women
Ann Burke
705-726-8032 ext. 3226
[email protected]


7% of women age 20 to 44 years were pregnant or breast
feeding at the time of their first contact with Smokers’ Helpline
Quit Coaches operate from a perspective that is womancentred rather than fetus-centred
◦ While we do not exclude concern for the fetus, the focus is on the
woman’s health and goals.


Use Motivational interviewing to support an identity shift from
smoker to non-smoker
Expanded proactive service offered, surrounding the due date
◦ Can receive up to 14 proactive calls from a Quit Coach