Smoking Cessation & Pregnancy

Susan A. Albrecht, PhD, RN

Donna D. Caruthers, PhD(c), RNUniversity of Pittsburgh

School of NursingSupported by: National Institute of Nursing Research

# RO1-NR03233

Presentation Overview

• Significance of smoking in the obstetrical patient

• Brief overview of findings for smoking cessation during pregnancy

• Review of study findings for smoking cessation with pregnant teenagers

• Implications for future work

SignificanceAdults• 25% of adults smoke regularly• 12.3% pregnant adults smoke during pregnancy

(Matthews, NVSS, 49:7, 2001)

Teens• 1/3 of all teens smoke• Teens at risk

Rural adolescents & Inner city femalesHighest rates of smoking in pregnancy (26%)

(Matthews, NVSS, 49:7, 2001)

Teen Smoking & Pregnancy

0

5

10

15

20

25

30

35

<15 15 - 17 18 - 19 Other

Allegheny County, 1995Age (Years)

%

Teen Health Risks

• Respiratory system damage

• Nicotine Addiction• Risk for other drug use (Surgeon General, 1994)

• Impairs physical endurance & performance• Decreased overall health with increases in

healthcare visits  (Arday,et al., Am J of Health Promotion,1995;10(2): 111-116)

Health Risks – Teen Pregnancy

• U.S Highest teenage pregnancy rate of developed countries. (CDC, 1999)

• Low birth weight due to poor prenatal nutritional intake

• Preterm delivery • Obstetrical risks double with teen

smoking(ACOG Educational Bulletin, 1997;240.)

Obstetrical Health Risks & Smoking• Ectopic pregnancy

• Placenta previa

• Abruptio placenta

• Preterm delivery

• Perinatal mortality

• Low birth weight – 2 times greater in smokers

• Intrauterine growth retardation(ACOG Educational Bulletin, 1997;240.)

Fetus and Infant Health Risks• Low birth weight• Sudden Infant Death Syndrome (SIDS)• Respiratory illnesses

Pulmonary, Otitis Media, Asthma

• School problemsLower scores on spelling & reading

tests Decreased attentionRisk for hyperactive behavior

• Increased Hospitalizations (Pollack, H.A., Am J Public Health, 2001; 91(3) &

ACOG Educational Bulletin, 1997;240.)

Background – Pregnant Adult

Smoking during pregnancy:Is it a temporary act?

At least 1/3 of all women who quit during pregnancy relapse before delivery. (Ershoff, 1995, Am J Prev Med)

Most women will relapse within 12 months of delivery. (Surgeon General, 2001)

2000 Clinical Practice Guidelines

• Guidelines state health care providers must screen and address for tobacco consumption with every smoker at every encounter

• Treatments as brief as three minutes are effective

• Use Five A’s to guide your efforts• Use Five R’s to guide your efforts with

patients unwilling to quit

Background – Pregnant Adult

Treatment types investigated• Harm Reduction – Exposure from spouse• Support for spontaneous quitters• Prenatal cessation programs• Relapse prevention programs

-Prenatal delivery

-Post delivery - telephone counseling

RCT- Adult Relapse

0102030405060708090

100

8 wksPP

6 mo 12 mo

Treat

Control

Delivery

%

Predictors of Relapse

Adult Pregnant Smokers

• Dependence/Tobacco use

• Passive exposure (spouse)

• Not breast feeding

• Self-efficacy• Education

Tobacco Control 2000, 9; supplement

Another Approach

Extending research to include pregnant teen smokers

Developmental Theory

Jessor’s Theory of

Problem Behavior Development• Teens engaging in one type of problem

behavior are more inclined to participate in other problem behaviors.

• Problem behaviors (e g. Smoking) focus on the role of peers.

Problem Behavior Theory

Social Environment

System

Personality System

Behavior System

Perceived Environment

System

Adapted from Jessor, Donovan, & Costa (1991)

Treatment Efficacy

• What are the short and long term differences in smoking behaviors among pregnant adolescents randomly assigned to either:

Teen FreshStart (TFS),

Teen FreshStart with Buddy (TFS-B), or

Usual Care (UC)?

Effect of Booster Sessions

• What is the effect of booster sessions on smoking behavior 1 year after study entry?

Booster sessions were anticipated to increase cessation rates as measured by self-report and saliva cotinine when controlling for cessation treatment (TFS & TFS-B).

Predictors of Relapse• Does a model consisting of baseline

characteristics of social environment, personal, and perceived environmental factors predict adolescent smoking at 12 months following study entry(T4).

Variables

Independent Variables

• Treatment Group Assignment

• Telephone Booster Sessions

Dependent Variables• Smoking Abstinence (Objective & Subjective)

1. saliva cotinine & carbon monoxide

2. self-report of smoking behavior

Data Collection

• Baseline – T1

• Following 8 week intervention – T2

• 6 weeks postpartum – T3

• 1 year following baseline – T4

Study Entry Criteria

Inclusion Criteria• 14 - 19 years old

• 12 - 28 weeks pregnant

• Smokes one or more cigarettes/day

• Read & understood English

Exclusion Criteria• Pregnancy

complications

• Confined to home for medical reasons

Sample

On average, pregnant female subjects (n = 142) were:

• White (49%; 39%)

• Single (32%)

• 17 yrs. old (s.d. ± 1.3)

• Gestation of 19 weeks (s.d. ± 7.2)

Baseline Tobacco Use• Initiated smoking: 12 years (s.d. ± 2.3)• Regular smoker: 13 years (s.d. ± 2.1)• Cigarettes/day before

pregnancy: 15 (s.d. ± 9.3)• Current

Cigarettes/day: 7 (s.d. ± 4.6)• Nicotine Dependence (FTQ):

4 (s.d. ± 1.9)• Previous quit attempt: 78%

Social Support for Quitting

0

10

20

30

40

50

60

70

MD RN Mom Dad Boyfriend

OtherFriend

%

Other Baseline Problem Behaviors

0102030405060708090

Alcoholuse beforepregnancy

Currentuse of

alcohol

Marijuanause beforepregnancy

CurrentMarijuana

use

%

Ethnic Differences

02468

101214161820

# Cigarettesbefore

pregnancy

# Cigarettesduring

pregnancy

White

Black

p < .001 p < .001

Teen Fresh Start - Intervention

Topics of group sessions1-3: smoking patterns & effects on

mom & baby 4: quit day 5: first steps of recovery 6: using coping skills 7: shared experience 8: celebrating healthy choices

Results – Following Intervention

0

10

20

30

40

50

60

70

80

90

UC TFS TFS-B

Smoking

Abstinent

Following Intervention

0

10

20

30

40

50

60

70

80

90

UC TFS-B

Smoking

Abstinent

p< .008

Results – 12 months Following Study Entry

0102030405060708090

100

UC TFS TFS-B

Smoking

Abstinent

Relapse – Baseline to 1 Yr.

0

50

100

150

200

250

300

Baseline T 2 T 3 T 4

Sal

ivar

y C

otin

ine

ng/m

l

UC

TFS

TFSB

Group, Carbon Monoxide, Booster

0

2

4

6

8

10

12

14

BLCO 2nd CO 3rd CO 4th CO

UC

TFS

TFS-B

Bst - TFS

Bst - TFS-B

CO

le

vel p

pm

n = 34

Group, Cotinine, Booster

0

50

100

150

200

250

300

350

BLCOT 2nd COT 3rd COT 4th COT

UC

TFS

TFS-B

Bst - TFS

Bst - TFS-B

Cot

inin

e le

vel n

g/m

l

n = 38

Predictors of AbstinencePredictor SE p O.R. Conf.

Interval

Attitude

Parent vs Peer

.57 .18 .002 1.77 1.2 – 2.5

Constant -5.03 1.17

Test of Model X2 = 12.9, 3df, p <.005

Predictors of AbstinencePredictor SE p O.R. Conf.

Interval

Attitude

Parent vs Peer

.44 .21 .035 1.54 1.03 – 2.3

ETOH Pre-

Pregnancy

1.7 .78 .029 5.46 1.2 – 25.0

Constant -5.13 1.34

Test of Model X2 = 11.9, 4df, p <.018

Conclusions

• Short-term tobacco abstinence was effective with the TFS-Buddy intervention.

• Neither the TFS or TFS-Buddy interventions were effective for long-term tobacco abstinence.

• Tobacco abstinence during teenage pregnancy may be one event in which a teen’s peers and parents are in agreement.

Implications

• Further research is needed to improve tobacco abstinence for pregnant adolescents and adults.

• Teens with heavy dependence may benefit from nicotine replacement medications, but research is lacking in this area.

Review Questions(developed by Supercourse Team)

• Why do you think at younger ages women now smoke more then men?

•What are the predictors of relapse?