Tobacco Cessation Interventions in Pregnancy

Eric L. Johnson M.D.

Physician Consultant

North Dakota Tobacco Quitline/Quitnet

Assistant Professor

Department of Family and Community Medicine

University of North Dakota

School of Medicine and Health Sciences

Objectives

• Assess status of Tobacco Cessation Interventions for Pregnant Patients by OB/GYN providers in North Dakota

• Translate this data into effective practice for OB/GYN providers

• Understand current Tobacco Cessation Interventions for Pregnant Patients

Tobacco Cessation Interventions by OB/GYN Providers in North

Dakota• Study by UNDSMHS NORTHSTAR

Research

• 7 question survey

• Mailed/e-mailed to 110 OB/GYN providers in North Dakota (OB/GYN, FP Physicians and Mid-levels) *

• 73 surveys returned (65% of total)*list compiled with assistance from North Dakota Chapter of the American College of Obstetrics and Gynecology

Results

Do you provide care to pregnant patients in your

practice?93.2%

6.8%

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

Do you assess pregnant patients for tobacco use?

98.6%

1.4%0%

10%20%30%40%50%60%70%80%90%

100%

Yes No

Do you offer tobacco cessation options to pregnant patients?

94.5%

5.5%

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

Which of the following cessation tools are offered in

your practice?89.0%

4.1%

28.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Information Pamphlets, TipSheets, etc

Videos Self Help Manuals

Are any of these materials designed exclusively for

pregnant women?

24.7%

75.3%

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

Do you offer counseling to pregnant patients regarding

tobacco cessation?89.0%

11.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Yes No

What types of counseling do you offer pregnant patients for tobacco

cessation?

78.1%

20.5%

60.3%

69.9%

0%10%20%30%40%50%60%70%80%90%

100%

In Office BriefCounseling

In HospitalCounseling

Referral to tobaccocessation

program/class

Referral to the NDTobacco Quitline

Do you prescribe medications to pregnant patients for tobacco

cessation?

46.6%53.4%

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

Which medications do you prescribe to pregnant patients for tobacco

cessation?

35.6%

21.9%

41.1%

6.8% 5.5%

34.2%

13.7%

1.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Gum Lozenge Patch Nasal Inhaler Inhaler Bupropion Varenicline Other Med

Conclusions of Study

• Most North Dakota OB/GYN providers are aware of Tobacco Cessation resources available to their patients who smoke

• Most North Dakota OB/GYN providers offer Tobacco Cessation to their pregnant patients who use tobacco

• Review of medication use for Tobacco Cessation in pregnant patients

Why Tobacco Cessation?

• Benefits in pregnancy and long term health• Reduce Cardiovascular Complications• Reduce Lung Disease• Reduce Cancer• Reduce Type 2 Diabetes• Economic benefit for individual and society

Smoking in Pregnancy

• Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11%

• Smokers tend to be from lower socioeconomic and educational classes

• WIC smoking population as high as 40%+ in North Dakota North Dakota Department of Health

Smoking in Pregnancy

• ~75% of pregnant smokers desire quitting

• ~25-30% actually quit during pregnancy

• ~50% resume after pregnancy

• Smoking Cessation is most successful prior to pregnancy

Ruggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.

Complications of Smoking in Pregnancy

• Fourfold increase in small for gestational age; Increased prematurity

• Twice the rate of spontaneous abortions• Increased risk of abruptio placentae,

placenta previa, premature and prolonged rupture of membranes

Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 George L, et al Epidemiology. 2006 Sep;17(5):500-5Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003

Complications of Smoking in Pregnancy

• Intrauterine growth restriction• Stillbirth• Ectopic pregnancy• Infertility• Poor wound healing/surgical outcomes

Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.

Fetal/Child Effects of Maternal Smoking in

Pregnancy• Sudden infant death syndrome (SIDS) and

increased respiratory illnesses in children • Possible Association with maternal

smoking and ADHD/Behavioral Disorders• Congenital Anomalies (i.e., cleft lip/palate,

cardiac)Linnett KM, et al Pediatrics 2005; 116: 462-467Malik S, et al Pediatrics 2008 Apr;121(4):e810-6Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90

Issues in Smoking Cessation

• Triggers• Mood changes• Withdrawal symptoms (most smokers

underestimate)• Weight gain• Lack of support• Exposure to other smokers

Smoking Cessation Interventions in Pregnancy

• Brief Office Counseling• Smoking Cessation Class (i.e., Public

Health)• Third Party Payer programs• Quitlines• Online programs (i.e., Quitnet)• Pharmacologic

Smoking Cessation Interventions in Pregnancy

• 5 A’s• ASK about tobacco use (Tobacco as

a vital sign)• ADVISE to quit• ASSESS willingness to make a quit attempt• ASSIST

• those who are ready, with appropriate treatment• those who are not ready, with motivational counseling

• ARRANGE for follow-up

USPHS 2008

• Pregnancy affords a great opportunity

• Multiple short term followup clinic visits

• Phone calls/e-mail/quitline/quitnet

• ASK every time

• Options every time

Smoking Cessation Interventions in Pregnancy

Pharmacotherapy

Pharmacotherapy• Nicotine replacement therapy (NRT)

– Gum– Patch– Spray– Inhaler– Lozenge

• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • All are first line non-pregnant USPHS 2008

Pharmacotherapy for Pregnant Smokers

• NRT- Category D. Secreted in breast milk. Crosses placenta

• Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester?

• Varenicline (Chantix)- No data (yet)

Oncken CA, Kranzler HR Nic Tob Res Nov 2009

Pharmacotherapy for Pregnant Smokers

• USPHS 2008 more limited recommendations vs USPHS 2000

• ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail

Nicotine Replacement Therapy in Pregnancy

• 6 randomized controlled trials 2000-2010

• 5 show possible benefit

• Higher birth weight in 1 trial

• Multimodal treatment-benefit?Oncken, C et al Obstetrics & Gynecology, 112(4), 859-867.Pollak, KI et al. American Journal ofPreventive Medicine, 33(4), 297-305.Hotham ED et al Addictive Behaviors, 31, 641-648.Hegaard HK et al Acta Obstetricia et Gynecologica Scandinavica,82, 813-819.Kapur, B, et al Current Therapeutic Research, 62(4), 274-278.Wisborg, K, et al Obstetrics & Gynecology, 96(6), 967-971.

Pharmacotherapy for Pregnant Smokers

• NRT use must be risk vs benefit

-heavy smoker, relapsers, other risk ? (i.e. CVD risk factors)

-if NRT used, intermittent (gum, lozenge)

-higher birth weight?• Buproprion? 1 study shows benefit *• Varenciline- not recommended presently

*Chan B et al J Add Dis (24) 19-23 2005

Pharmacotherapy for Pregnant Smokers

• Smoking, Nicotine, and Pregnancy Trial

• Currently underway (UK study)

• Projected publication is 2013

Behavioral Interventions

In Office Counseling

• Brief

• No additional cost

• Slightly increases quit rates in non-pregnant adults

Classes

• Maybe difficult to access in rural areas (variable)

• Availability• Public Health, American Lung Association,

Employers• Sometimes cost• Effective

Quitlines

• Free• Widely available• Effective • ND Quitline ~30% 13 month quitrate in

general population• ND Quitline Free NRT for qualifying• MN Quitplan

Online Services

• Third party payers

• ND Quitnet: Premium content to ND residents, launched Feb 2010

• ND Quitnet Free NRT

nd.quitnet.com

Free to all North Dakota ResidentsFree NRT for qualifying

1-800-784-8669

Quitlines

• Other surrounding states have quitlines

• 1-800-QUITNOW is universal in U.S.

• Third Party Payers, Health Care Systems

Nicotine Addiction

• Smokers are addicts……………..• Nicotine is a highly addictive substance….• Successful treatment is based on addiction

treatment principles……• Behavioral/Cognitive/Motivational

Interviewing• Pharmacotherapy (when appropriate)

Challenges for Long-Term Tobacco Cessation

• Pregnant smokers tend to not be “committed quitters”

• Limitations of medication prescribing for pregnant/lactating smokers

• Smoking is nicotine addiction, not just a bad habit

Summary

• Smoking is problematic in pregnancy

• Long Term Health issues- mother and baby

• Nonpharmacologic resources first line for most pregnant smokers

• Possible limited role for NRT in select patients

Review Articles

• Crawford J, et al Smoking Cessation in Pregnancy: Why, How, and What Next Clinical Obstetrics &Gynecology June 2008

• Oncken CA, Kranzler HR What do we know about the role of pharmacotherapy for smoking cessation before or during pregnancy

Nicotine Tob Res. Nov 2009

See/Download My Slides:

• http://www.med.und.edu/familymedicine/slidedecks.html

Contact me:

eric.l.johnson@med.und.edu

ejohnson@altru.org

701 777 3811 or 701 795 2861

Acknowledgements

• Dr. Charles Christianson, NORTHSTAR, UNDSMHS

• Jessica Behm, NORTHSTAR, UNDSMHS• North Dakota Chapter of the American College

of Obstetrics and Gynecology• North Dakota Department of Health, Division of

Tobacco Prevention and Control