Interventions for Smoking During Pregnancy

Patricia Cluss, Ph.D.

Pittsburgh Mind-Body Center

Summer Institute 2007

Review of AHCPR/PHSSmoking Cessation Guideline

(1996 & 2000)

• Effective smoking cessation treatments exist• Every smoker should be offered an effective

treatment• Health care clinicians: screen for tobacco use

status of every patient • Brief cessation treatments are effective; at

least a minimal intervention should be provided to every smoker.

Effective Treatment

• Three effective treatment elements: pharmacological aides, social support, skills training/problem solving

• Dose-response relationship: More intense treatment = greater effectiveness

• Identify and intervene with smokers at every health care visit

Pharmacotherapies

• Nicotine replacement therapies (patch, gum, lozenge, nasal spray, inhaler)

• Zyban (Wellbutrin/bupropion)

• Chantix (varenicline)

Key components of programs for all smokers

• Information• Behavioral problem solving skills• Coping strategies• Attention to motivation and readiness• Social support• Relapse prevention

The 5Asfor Health Care Settings

• Ask

• Advise

• Assess

• Assist

• Arrange

5A Results

• Provider Ask rates have increased from 10-30% a decade ago to about 60% in 2004.

• Advice rates to identified smokers is about 70% now

• Rates of the last 3 of the 5As continue to be poor.

Other Mnemonics / Plans

• Ask, Advise and Refer

• Ask and Act

Expert committee has been reconvened for a guideline update within next several years

SMOKING DURING PREGNANCY

Health RisksSmoking during pregnancy is one of the major preventable risk factors for perinatal morbidity

and mortality:• Intrauterine growth retardation (low birth

weight, length, head circumference)• Increased risk for ectopic pregnancy,

miscarriage and premature delivery• Adverse long-term effects on children’s

neurocognitive development• Adverse effects on postnatal height growth• Postnatal impaired arousability from sleep

(associated with SIDS)

Smoking during Pregnancy as a Health Care Crisis for the Underserved

• Reducing smoking during pregnancy by 1% in U.S. over 7 years would prevent 57,000 LBW infants and save $572M in direct medical costs.

• Low SES women are much more likely to smoke during pregnancy (23%) than higher SES women (5%).

• At MWH prenatal clinic, 50% of pregnant women smoke.

How many women smoke during pregnancy?

• Prevalence between 1987 and 1996 reduced from 16% to 12%.

• Pregnant women are about half as likely as nonpregnant women to be smokers.

• The median number of cigarettes smoked for pregnant women has remained a fairly constant 10/day.

Who smokes during pregnancy?(Race & ethnicity)

21

17

10

43

0

5

10

15

20

25

American Indian

White

Black

Hispanic

Asian-PacificIslander

%

Source: National Center for Health Statistics

Who smokes during pregnancy?

15

912

8

19

23

16

5

9

14

0

5

10

15

20

25

Age Married? Education Employed?

Age:Teen/21-30/>30 Married: yes/no

Education:< hs/hs grad/> hs Employed: yes/no

%

Who smokes most during pregnancy?

Low SES women,regardless of how SES is measured

• Least educated: high school or less• Lowest income: women on Medicaid are

2X as likely to smoke as those with private insurance

• Of employed women, those with the lowest status jobs (5X greater than those with highest status jobs)

Who quits when pregnant?

• 25% quit when they become pregnant (spontaneous quitters)

• Lighter smokers• Older• Having their first baby• Smoking for a shorter amount of time• Higher education level• Higher SES• Partner who is a nonsmoker

The good news & the bad news

The Good News

With increased availability of information about the harmful effects of smoking, more women are aware of the value of quitting before or at the beginning of a pregnancy.

The Bad News

For those who don’t,

it’s hard.

• Quitting any time during pregnancy is beneficial

• More intensive interventions are preferred

PHS Guideline recommendationsfor pregnant smokers:

Cutting Down as a Goal for Pregnant Smokers?

Substance abuse

Nonpregnant smokers

Alcohol abuse

Pregnant smokers:dose-response relationship

What works?

• Tailoring the intervention for pregnancy

• Brief counseling of 5-10 minutes

• Nicotine replacement therapy, Zyban, or Chantix???????

• Provide cessation interventions for smoking partners??

Working with low SES pregnant smokers

• Cessation programs are less effective for low vs. high SES smokers

• Low SES women report more stressful events, more perceived stress, more negative appraisal from family, less social support & higher addiction to nicotine

These conditions result in lower:

Motivation to stop smoking

&

Confidence in their ability to stop

Relapse

• 15-30% relapse during pregnancy

• 55-70% relapse within 1 year postpartum

• 60% of those relapse within 1 month

Factors associated with relapse

• Decreased motivation to be a nonsmoker in the postpartum

• Decision not to breastfeed/short duration of breastfeeding

• Concern about losing weight in the postpartum

• Changes in social support for not smoking

Interventions for low SES pregnant smokers should include:

• More intensive interventions• Focus on reducing stress • Identification of depression & other MH

needs• Increased focus on social support• Attention to postpartum relapse

Problems with Screening During Pregnancy:

• 14% of privately insured women do not disclose that they smoke

• 25%-40% of women seen in public maternity clinics do not disclose

Improving the validity of self-report of smoking status

“Do you smoke?”• I smoke about the same as or more than before

I was pregnant• I’ve cut down since I found out I was pregnant• I have quit smoking since finding out I was

pregnant • I wasn’t smoking around the time I found out I

was pregnant and I don’t currently smoke

Pittsburgh’s Least Well-Known Claim to Fame:

#1 in smoking during pregnancy

of any large US City*Pittsburgh 24%

NYC 5%

Boston 8%

Chicago 10%

Philadelphia 18%

Cleveland 20%

Top 50-city avg. 11%

Source: Annie E. Casey Fdn. Kids Count Special Report, 1999

The Pittsburgh STOP (Stop TObacco in Pregnancy) Program

• An outcomes-driven evidence-based program for underserved pregnant smokers

• Almost 900 pregnant smokers and recent quitters have participated since 2000 (60%/40%)

• Based at WPIC with community outreach at Magee-Womens Hospital and other community locations

Pittsburgh STOP ProgramReadiness-based recruitment &

intervention strategies

Sure you can’t/don’t want to quit, butwilling to think about cutting down?

Thinking about quitting, but not sure?

Ready to quit?

Race/Ethnicity

55

40

41

0

10

20

30

40

50

60

White

Black

Biracial

Asian

%

Pittsburgh STOP Program

• Mean age 23; range from 14-42• Marital status: 83% single• Education: 41% did not graduate HS• Income: 56% have yearly income < $10K• Insurance: 91% Medicaid or uninsured• # other children: avg. = 1; range 0-7• Pregnancy unplanned for 85%• D&A: 35% admit concurrent use• Current domestic violence: 20%

STOP ProgramInnovative features in the STOP Program:

• Incentives:– Small baby gift for attending sessions– Small gift for self for meeting cessation or

cut-down goals

• Exhaled air carbon monoxide (CO) monitoring

CO Monitoring

• Originally built into the design as an evaluation measure to confirm self report of smoking status

• Initial concern about effect of this measure on participant-interventionist relationship

What has been most helpful?

IncentivesProblem solving

2%

Support from interventionist 31%

Education on health effects of smoking

13%

Saw how cutting down improved my

health 4%

CO monitoring 43%

Other2%

5%

CO Monitoring

• Based on participant feedback, CO monitoring is now used as a program element to motivate change.

STOP Participants’ CO LevelsAll those who entered as smokers

20

13

0

2

4

6

8

10

12

14

16

18

20

Intake 3rd session

A CO score of 8 or less is indicative of no smoking

Smokers’ Pre-delivery CO Levels

Those with 3 or more pre-delivery readings

19

11

0

2

4

6

8

10

12

14

16

18

20

Intake Last pre-delivery session

CO score of 8 or less is indicative of no smoking

CO Monitoring as a Motivator

• Baseline score with printed and verbal info about how higher levels of CO/lower levels of oxygen affect the mother and the fetus

• Used as an example of other harmful physiological effects of smoking on mother and fetus

• Weekly CO goals

• Chart for ongoing CO monitoring

STOP Program Results

• Drop out rate low at 14%• Quit & stay quit rates:

– 26% quit rate for those who enter as current smokers; most who do not quit do cut down

– 93% stay-quit rate for those who enter as recent quitters

• Birth outcomes ex-smokers vs. smokers:– Significantly higher birth weights (11 oz.): only

13% born LBW vs. 24% for smokers (p=.02)– Longer gestational age (38 vs. 37 weeks): only

24% born preterm vs. 34% for smokers (p=.10)