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Smoke-Free PregnanciesCollaborating Organizations
Centers for Disease Control & Prevention
Robert Wood Johnson Foundations
Smoke-Free Families ProgramAmerican College of Obstetricians & Gynecologists
Agency for Health Care Policy and Research
Health Resources and Services Administration
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Dangers of Smoking
Before, During and
After Pregnancy
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Whats in a Cigarette?
Blended tobacco plus:
Artificial milk chocolate Artificial tobacco flavor
Licorice flavor
Fructose syrup
Molasses Sucrose
Vanilla
Casing
Cedarwood oil Ethanol
Invert sugar
Isovaleric acid
Glycerol Hexanoic acid
Methanol
Olibanum oil
Patchouli oil Phenylacetic acid
Propylene glycol
Valerian root
Vanillin Vetiver oil
3-methylpentanoic acid
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Smoking before Pregnancy
Decreased ovulation
Impaired tubal transport
Reduced sperm count and motility The greater the number of
cigarettes smoked, the greater the
effect on fertility
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Smoking during PregnancyAdverse Outcomes
Preterm birth
Growth retardation
Low birthweight Sudden Infant Death Syndrome (SIDS)
Childhood illness
School problems
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Smoking during PregnancyPregnancy Outcomes
Outcome EffectMean Gestational Age Little or None
Preterm Birth RR = 1.4
Growth Retardation RR = 2.4Mean Birth weight - 149 grams
A small proportion of preterm births, but 36% ofall growth retardation is attributable to smoking.
Kramer, 1987
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Smoking during Pregnancy
RiskFactors
In the developed world, cigarettesmoking is the most powerful known
determinant of fetal growth retardation.The relationship between smoking andlow birthweight is one of the mostconsistent findings in the epidemiologicliterature.
Stein & Susser
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Smoking during Pregnancy
Reasons for Reduced Fetal Growth
Lower maternal weight gain
Vasoconstriction and decreaseduterine blood flow
Carbon monoxide toxicity
Increased cyanide production
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Smoking during Pregnancy
Passive ExposureMaternal exposure to passive
smoking in early pregnancy more
than doubles the risk of delivering
a small-for-gestational-age infant.
Dejin-KarlssonAJPH, 1998
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Smoking during PregnancyGrowth Retardation in Developed
Countries-- Risk Factors
Kramer, WHO Bulletin, 1987
Cigarettesmoking
Low weight
gain
Low pre-
pregnancyweight
Other (36%)
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Smoking during PregnancyLow Birthweight
0
5
10
15
20
25
3035
LBW
(%)
0 1-5 6-10 11-15 16-20 21-30 31+
Cigarettes per Day
Simpson, Am J OBGYN, 1957
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Smoking during PregnancySIDS
Maternal smoking during pregnancyhas been associated with a 2-4 fold
increased risk of SIDS Maternal postpartum smoking and
smoking by others in the household
has also been associated with SIDS
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Smoking after Pregnancy
Children of smokers are more likelyto experience:
Sudden Infant Death Syndrome (SIDS)
Respiratory infection includingbronchitis and pneumonia
Otitis media
Asthma
Hospitalization
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Smoking during Pregnancy
Long-Term Effects on Children
Decreased IQ
Lower scores on spelling andreading tests
Poorer school performance
Shorter attention span
More likely to be hyperactive
Decreased height
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Smoking during PregnancyLong-Term Effects on Children
Children of mothers who quit
smoking during pregnancy scored
5 points higher on IQ tests and hadbetter motor skills compared to
those whose mothers did not quit.
Sexton, 1990
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Which Women
Smoke?
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Risk Factors For Smoking
Low Education
Young Age
White Race
Medicaid Recipient
Partner Who Smokes
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Smoking during Pregnancy
By Education
Less than High School 26%
High School Graduate 18%Some College 11%
College Graduate 3%
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Smoking in Grade SchoolUSA 1975-1996
0
10
20
30
40
50
1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1996
Year
Percent
12th Grade
10th Grade
8th grade
1 or more cigs. last 30 days
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Smoking Among Pregnant WomenUnited States, 1965-1996
0
5
10
15
20
25
1989 1990 1991 1992 1993 1994 1995 1996
Year
Preva
lence(%)
Final Natality Statistics, 1989-1996
S ki d i P
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Smoking during PregnancyBy Race and Ethnicity
United States, 1996
0
5
10
15
20
25
Prevale
nce(%)
AmericanIndian Alaska
Native
White non-Hispanic
Black non-Hispanic
Hispanic Asian PacificIslander
Final Natality Statistics, 1996
21%
17%
10%
4% 3%
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Who Smokes before PregnancyBy Source of Care and Payment
Source Percent
Health Department 60%Medicaid (Any Source) 60%
Private MD and Insurance 30%
Adams from PRAMS
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Smoking during PregnancyBy Employment Status
0
5
10
15
2025
30
35
40
4550
CurrentS
mokers%
Lowest Highest
Employment Grade
35%
25%
15%
10%8% 7%
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Smoking Prevalence in the USA
20
25
3035
40
45
5055
60
1950 1960 1970 1980 1990 2000
Years
Percentage
Women
Men
JAMA, 1989:26
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Smoking Among Women
In 1994, more than 14 million U.S.women aged 15-45 years were smokers
800,000 to 1,000,000 of these womenbecome pregnant each year.
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Smoking during PregnancyLong-Term Effects on Woman
Increased Decreased
Cancer Life expectancy
Heart DiseaseChronic Lung Disease
Stroke
142 000 Deaths Attributable to Cigarette Smoking
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142,000 Deaths Attributable to Cigarette Smokingin Women - United States, 1990
36,000
30,000
10,000
25,000
8,000
34,000
CDC, MMWR, 8-27-93
Ischemic Heart Disease Lung Cancer
Stroke
Chronic Lung DiseaseOther Diagnoses
Other Cancers
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Diagnosis of Smoking
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Diagnosis of Smoking
Deception rates, as confirmed by
comparing results of biochemical
tests with self-reports, are high.They may reach 50% in some
populations.Alabama SCIP, 1998
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Diagnosis of Smoking
Biologic markers are the goldstandard for diagnosing smoking or
documenting cessation.
A structured questionnaire correlates
better with biologic markers than
does asking a pregnant woman if she
smokes and how much.
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Diagnosis of Smoking
Biological Markers:
Thiocyanate
Cotinine
Carbon Monoxide
Urine
orSaliva
Measured in:
Expired air
Recommended
Multiple Choice Question
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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 foundout 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 waspregnant, and I dont currently smoke cigarettes.
Mullen et al., 1991
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Cessation and
Treatment Programs
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Spontaneous Cessation
Between 10 and 40% of pregnantsmokers quit spontaneously.
The percentage depends on themothers age, race, education,
duration and level of smoking.
Self Initiated Rates of Cessation
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Self-Initiated Rates of Cessationamong Pregnant Women
40% of pregnant women who areprivately insured quit smoking beforetheir first prenatal visit
20% of pregnant women who arecovered by Medicaid quit smokingbefore their first prenatal visit
Windsor, Li, Lowe, et al., 1993Ershoff, Mullen, Quinn, 1989
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Spontaneous Quitters
Are less addicted
Appear to be more concerned
about effect of smoking on baby Have more years of school
Smoking during Pregnancy
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Smoking during PregnancyPossible Interventions
Clinical:cessation counseling &pharmacotherapies
Community-based:
mass media education
Policy:tobacco taxes
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Smoking Cessationduring Pregnancy
Message from the Field
We are funded and very anxious to
do a smoking cessation programfor pregnant women, but we dontknow what to do.
Healthy START ProgramSyracuse, NY, October 1998
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Clinical Cessation Programs
Many different interventions have been used inan attempt to reduce or eliminate smoking inpregnancy:
Physician Advice
Self-help manuals and other printed materials
Video-tapes
Group clinics
Psychotherapy
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Smoking Cessation
during Pregnancy
ClinicalCessation Programs
Many methods have not been tested
rigorously in randomized trials.
Most tested methods have notproduced a significant increase in
cessation.
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Best Clinical Practice
Meta-analyses reviewing smokingcessation studies have concluded that:
For women smoking at the first prenatalvisit, the provision of a single 5-15 minutecounseling session by a trained providerplus appropriate print materials canincrease cessation rates from 5-10% to15-20%.
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy5-15 Minute Counseling Session
Determine amount smoked Review smoking-associated risks to
fetus, infant and mother
Review benefits to cessation Teach methods to stop smoking
Ask for commitment to stop smoking
Ask for commitment to use self-helpmanual
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Smoking Cessation
during Pregnancy5-15 Minute Counseling Session
The 5-15 minute counselingsession appears to work equally
well with women of various
ethnic and racial groups.
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Cessation Programs
In pregnancy, less intensive advice has notsignificantly increased cessation over
background.
In pregnancy, more intensive interventionshave generally not increased cessation
rates above those achieved using a 5-15
minute counseling session by a trainedprovider.
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Current Barriers
They question the effectiveness of counseling There are no specific ACOG recommendations
Their staffs are untrained in this area
There are too many intervention choices
There is no reimbursement for counseling
Other than advice to quit, most obstetric providersdo not include smoking cessation counseling
among their services because:
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Print Materials
Adverse effects of smoking onpregnancy
Techniques to help quitting
Benefits to be gained from quitting
and for reducing smoking
Print materials should be tailored forpregnancy and should present:
Smoking Cessation
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gduring Pregnancy
Provider Training A non-physician provider (nurse/
nutritionist/social worker/etc.) can be
trained and certified on site to screen andcounsel using self-instructional
educational/training materials.
The total time needed for this training isless than 3 hours.
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Implementing Cessation Programs
Lessons Learned
Execution matters
Systems matter
Incentives (to providers) work
The Guide to Community Preventive Service
Implemen
ting Cessation Programs
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Implementing Cessation Programsin MCOs
Develop administrative commitment Involve staff early in implementation
planning
Assign staff to monitor implementation Train clinical & support staff
Adapt procedures to specific setting
Evaluate and give feedback to staff
Adapted from Make Yours a Fresh Start Family
Cessation Programs
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Cessation Programs
Cost - Effectiveness
Using the 5-15 minute counselingsession plus print materials, various
investigators have estimated that therewill be a $3 reduction in medical costsfor every $1 spent on the intervention.
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Smoking Cessation
during PregnancyThe 5-15 minute counseling
intervention has not significantlyincreased smoking cessation in
heavy smokers.
I t k b th NRT ( t h
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In non-pregnant smokers, both NRT (patch,gum, inhaler) and antidepressants
(buproprion) approximately double cessationcompared to behavioral methods.
In very limited studies in pregnant women,
NRT was not associated with adverseoutcomes, but did have a short-term influenceon fetal breathing movements and fetal heartrate variability.
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There are no existing studies in which thesafety or efficacy of either antidepressants
or NRT has occurred in a sufficiently large
pregnant population to determine whatmight occur with large-scale use.
Smoking Cessation during Pregnancy
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Smoking Cessation during Pregnancy
Pharmacologic Interventions
Since the heaviest smokers do not appearto respond well to behavioral interventionsused alone, the use of adjunctive
pharmacologic approaches to achievecessation in these women should beexplored.
The efficacy and safety of these
pharmacological approaches duringpregnancy is unknown.
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Smoking Cessation
during PregnancyPharmacologic Methods
Nicotine ReplacementTherapy (NRT)
Buproprion/Zyban
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Why Offer a SmokingCessation Program
during Pregnancy?
Substance Use in Past Month Among Women
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Aged 15-44 Years
0
5
10
15
20
25
Prevalence(%)
Cigarettes Alcohol Illicit Drugs
National Household Survey on Drug Abuse, 1994-199
20.6%
2.4% 2.7%
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Smoking Cessationduring Pregnancy
Stopping smoking is one of the
few preventive measures likely
to have a substantial impact on
pregnancy outcome.
Smoking Cessation
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Smoking Cessationduring Pregnancy
Pregnant smokers who stopsmoking at any time up to the
30th week of gestation haveinfants with higher birthweightthan women who smokethroughout pregnancy.
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gduring Pregnancy
Reductionsin cigarette smoking
documented by a decrease in
cotinine or other biologic markers,or by self-report, have been
associated with an increase in
birth weight.
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S o g Cessat oduring Pregnancy
Smoking cessation can also
result in a permanent change
in life-style that will reduce therisk of smoking-related
chronic diseases.
Postpartum Smoking Cessation
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0
10
20
30
40
50
60
7080
90
100
0 1 2 3 4 5 6Months from Delivery
%
Abstaining
Mullen, 1990
Smoking Cessationd i P
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during Pregnancy
Postpartum Maintenance
Womans health
Next pregnancy
Childs health
Up to 35% of women who stopsmoking during pregnancy remain
nonsmokers, benefiting:
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during Pregnancy
Reduction of Medical Care Costs Direct health care costs
prenataldelivery
postnatal
Indirect costsyears of life lost--infant mortality
lost productivity of mother
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during PregnancyReduction of Medical Care Costs
The excess cost of neonatal care for theinfant of a smoker averages $500
Prenatal smoking interventions may yield a
benefit-cost ratio of 3:1 for the initial hospitalstay and 6:1 using a longer time frame
The break even point of prenatal smoking
interventions is estimated to cost $32-$80
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The Future
Goal
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Goal
Achieve widest possible
utilization by providers of an
officially endorsed, pregnancy-specific, smoking cessation
intervention
Next Step
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Next Step
Private providers Public providers
Managed care providers
Develop a dissemination strategyto achieve maximum utilization ofthe intervention by:
Smoking Cessation during Pregnancy
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Dissemination Goal
Dissemination by the CDC and other federalagencies, ACOG, and the RWJF TobaccoControl initiatives has the potential to
achieve a nationwide adoption of a single,pregnancy-specific, smoking cessationintervention to be delivered by all providers,thereby setting the standard of care for
pregnant smokers.