Smoking Cessation in Pregnancy

1
Smoking Cessation in Pregnancy

• Richard O. Davis, MD
• Department of OB/GYN
• Division Maternal Fetal Medicine
• University of Alabama at Birmingham

2
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

3
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 20th Century
• increased smoking

4
The FactsTobacco 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 2006145839-44

5
The FactsSmoking

• Increased cardiovascular disease
• Increased lung cancer
• 68,000 women die annually
• Responsible for 1 in 4 cancer deaths in women
• 27,000 more deaths each year than breast cancer

Public Health Service, Office of Surgeon General
2001
6
The FactsInitiation 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 2006367749-53
7
Women Who Smoke

• High parity
• Lesser education
• Low economic status
• Poor coping skills
• Exposure to domestic violence
• Job strain

8
Cultural InfluenceWomen Who Smoke

• Native American/Alaskan 29
• White (Non-Hispanic) 20
• Black (Non-Hispanic) 17
• Other 18
• Asian 5

MMWR 200453427-51
9
The FactsComplications in Pregnancy

• Increased risk of ectopic pregnancy
• Placenta previa
• Placenta abruption
• Stillbirth
• Premature rupture of membranes

Clin Obstet Gynecol 200851(2)419-35
10
Complications in PregnancyThe Likely Culprits

• Nicotine vasoconstriction
• Fetal serum (15) and amniotic fluid levels (88)
  higher than maternal
• Carbon Monoxide Diminished tissue oxygenation
• Fetal levels higher (15) than maternal
• Cyanide Harmful to rapidly dividing cells
• Cyanide levels are higher in smokers

Clin Obstet Gynecol 200851(2)419-35
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Complications in PregnancyOther Toxic Compounds

• Ammonia
• Polycyclic aromatic hydrocarbons
• Vinyl chloride
• Nitrogen oxide

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Complications in Pregnancy(Heavy Smoking gt 20
cigarettes/day)

• Low birthweight (lt2500 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 200851(2)419-35
13
Maternal Life Time Smoking Complications

• Atherosclerotic disease
• Lung cancer
• COPD
• Increased risk of ectopic pregnancy
• Premature menopause
• Infertility
• Osteoporosis

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Infants, Children and Secondhand SmokeIncreased
Risks

• Respiratory infections
• SIDS
• Asthma/bronchitis
• Short stature
• Hyperactivity
• Decreased school performance

Clin Obstet Gynecol 200851(2)419-35
15
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
16
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 As and 5 Rs (endorsed by ACOG and
  National Cancer Institute and British Thoracic
  Society) for patients unable or reluctant to quit

Clin Obstet Gynecol 200851(2)419-35
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The 5 As

• 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

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The 5 Rs

• 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

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Smoking Cessation InterventionWhy 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

20
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 20002833244-254

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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 20051921856-1862

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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 1994841127

23
Role of CounselingMeta Analysis

• Brief, intense counseling 5-15 minutes
• Cessation rate 5-10
• Brief counseling and pregnancy specific
  educational printed material
• Cessation doubles to about 20

24
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 61 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

25
Nicotine Replacement Therapy

• RCT by Wisborg et al showed that nicotine patches
  did not affect cessation rate, but did increase
  BW
• Under-powered
• Low compliance
• RCT by Oncken et al demonstrated that nicotine
  gum had no effect on cessation rate
• 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 96967-971.
• Oncken et al. 2009. Obstet Gynecol
  112859-867.
• Pollack et al. 2007. Am J Prev Med 33297-305.

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Bupropion

• Aminoketone that is a weak reuptake inhibitor of
  dopamine, norepinephrine, and serotonin initially
  utilized as an antidepressant
• In non-pregnant adults, multiple studies have
  shown that bupropion significantly improves
  smoking cessation rates
• 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)
• 3 other studies showed no association

Hurt et al 1997. NEJM 3371195-1202 Alwan et al
2010. Am J Obstet Gynecol 20352e.1-6. Chun-Fai-C
han B et al 2005. Am J Obstet Gynecol 192932-6.
27
U.S. Department of Health and Human
Services Clinical Guidelines 2008

• Pregnant women should be actively counseled and
  provided information regarding benefits of
  smoking cessation
• Smoking cessation in early pregnancy is
  preferred, but cessation at any time is beneficial

28
U.S. Department of Health and Human
Services Agency for Healthcare Research and
Quality (AHRQ) Treating Tobacco Use and
Dependence 2008 Update

• No recommendation regarding medication use during
  pregnancy
• NRT is probably safer than nicotine exposure from
  cigarettes
• Inconclusive evidence that cessation medications
  boost abstinence rates in pregnant smokers

29
Postpartum Period and Relapse

• 50-90 relapse within first year after delivery
• No proven strategies to prevent relapse
• Continue encouragement, enforce benefits of
  cessation, reinforce patients desire to be a
  good mother