SMOKING IN PREGNANCY

Dr Catherine Angell

Plan for this sessionPhysiology of smoking in pregnancy

Physiology of smokingRisks to the woman of smoking in pregnancyRisks to the infant and childRisks to mother and infant of passive smoking

Smoking behaviour in pregnancyReasons why women smoke during pregnancyChanging smoking behaviourThe role of the midwife in relation to smoking

Write 3 words to describe how this

image makes you feel...

...keep hold of this for

later

Physiology of smokingNicotine

Tobacco leaves in cigarettes contain nicotineNicotine is an anti-herbivore chemical found in the nightshade family of plantsIt combusts at only 95oC allowing its vapour to be released when the leaves are burnedNicotine is absorbed through skin and membranesIt is then absorbed into the bloodstream

(Katzung et al., 2006)

Physiology of smoking

Nicotine in the bodyNicotine circulates the body to the brain and crosses the blood-brain barrier in 7 secondsIt binds to nicotinic acetylcholine receptorsDopamine, a ‘feel good’ neurotransmitter, is released in greater quantitiesThe body reduces the production of dopamine to try compensate for the raised levelsBUT the body then increases the number of receptorsAs a result the body craves repeated doses of nicotine

(Katsung et al., 2006)

Physiology of smokingWhy do people enjoy smoking?

Dopamine • feelings of pleasure and satisfaction

Adrenaline• increased heart rate, blood pressure, respiration • release of glucose from the liver• raised blood sugar and appetite suppression

Norepinephrine• increased concentration, sharpness and arousal

Seratonin• calming, pain-killing, sedative effect

Nicotine is unique in the change in effect achieved by different doses

Physiology of smoking

Smoking has particular healthimplications for women

Infertility/delayed conceptionEarlier menopauseOsteoporosisCervical cancerBreast cancer (Odiase, 2009)

Heart attack/stroke if using oral contraceptives

PUBLIC HEALTH ISSUE

Smoking during pregnancy

Researching risk of pregnancy smoking is problematic because

Smoking habits related to social group• Poverty• Less educated• General health• Delay in seeking health care• Other risk factors ; diet, alcohol, medication, drugs• Less likely to breastfeed

Women may be reluctant to disclose level of smokingExposure to passive smoking

(Jarvis and Wardle, 1999)

???

Risks to the woman of smoking during pregnancy

Ectopic pregnancyMiscarriagePlacenta praeviaUrinary tract infectionsPlacental abruptionPre-term labourPremature rupture of membranesHaemorrhage Inadequate breast milk production (Castles et al, 1999)

But not for:Pre-eclampsia (Engel et al., 2008)

PIH (Yang et al., 2006)

Gestational diabetes (Wendland et al., 2008)

Risks to the infant

Nicotine transfer to the infant

Nicotine and carbon monoxide move easily across the placenta

Nicotine and carboxyhemoglobin concentration is 10-15% higher in the fetus than in the mother

Nicotine is also carried in breast milk (Briggs and Freeman,

2005)

Smoking during pregnancy

Note down as many physical effects of

smoking for the FETUS as you can

Risks to the infant IUGRLow birth weightPremature birthPoorer outcomes for

pre-eclampsiaNeonatal mortalityCongenital malformations• Cardiovascular • Cleft lip and palate• Genitourinary• Talipes

Sudden infant death syndrome (SIDS)Respiratory problems,

eg. pneumoniaAsthmaEar nose throat problems, eg. glue earUndecended testes

(Edwards and King, 2007; Graham and Smith, 2007; Malik et al., 2008; Pipkin, 2008))

Risks to the childObesityAsthmaRespiratory disease

MeningitisChildhood cancers (linked to paternal smoking at conception)

DiabetesEarlier menarche (start of periods) and menopauseFertility difficultiesDelayed developmentEmotional problemsBehavioural problemsMore likely to be a smoker

(Gilman et al., 2008)(Sterjfelt et al., 1986; Hofhuis et al, 2003)

Smoking in pregnancy

Smoking in pregnancySmoking rates amongst pregnant women in the UK:

23% in 199519% in 200017% in 2005

(Baxter et al., 2009)

But RCM has noted concern about rises in pregnancy smoking rates since 2005

Why women smoke in pregnancyPhysiologically more difficult to break addiction

during pregnancy...

Adaptation to pregnancy alters how nicotine is metabolisedNicotine clearance improves by 60%Rapid clearing results in a rapid decrease in blood nicotine levelsWomen experience sharper withdrawal and increased craving

(Ebert et al., 2008)

Why women smoke in pregnancy

Get into pairs. Describe the history of a woman who you have cared

for who was/is a smoker

What factors in her life do you think may have caused her to smoke?

Write these down

Why women smoke in pregnancyStress

Experience of smoking appears to offer relief from stress• Pregnancy anxiety, unplanned pregnancy• Money, work, housing• Partner, children, family• Guilt because of smoking

Women may believe smoking is better than stress for themselves, their baby and familyBUT smoking does not actually reduce stress...smoking increases stress hormones and having a cigarette generates dopamine which masks these

(Ebert and Fahy, 2007)

Why women smoke in pregnancyCoping with depression and anxietySocial reasons• Habit and lifestyle• Fitting in with partner/social group (Wakefield et al 1998)

Lack of understanding of risks• Risks of smoking distant and abstract (Graham, 1993)

Weight issues• Weight gain• Small baby=easier birth (Stillman et al., 1998)

Support from health professionals does not meet needs

Changing smoking behaviour

GO back to the woman whose history you described earlier

Did she try to give up?What support did she get?Did it appear to be successful for her?

Changing smoking behaviour

More women stop smoking during pregnancy than at other times in life (McBride, 2003)

33% of women stop smoking during pregnancy

(Edwards and Byrom, 2004)

BUT 25% smoke again with a year (Edwards and Byrom, 2004)

Disadvantaged women least likely to cease smoking (McBride, 2003)

If the woman’s partner smokes she is much less likely to give up (McLeod et al 2004)

Changing smoking behaviour2 major reviews

• Cochrane (2004)• NICE (2009)

Concluded there was a lack of good quality evidenceLittle research has identified the views of women who continue to smoke in pregnancyFurther research required

Changing smoking behaviourSystematic review identified 48 trials......

Methods used for smoking cessation included:Information about cessation schemesCounsellingGroup counsellingPeer supportTelephone supportChemical testing and positive feedbackFetal monitoring and feedbackNicotine replacement therapyRewards and incentives (Lumley et al, 2004)

Changing smoking behaviour

Problems that women experience with smoking cessation advice...Smoking viewed as a lifestyle choice not an addictionThe need to smoke is not understoodAssumption that women will want to give up smoking‘Nagging’ and criticisingFeelings of shame and guiltLack of self-efficacy in pregnancy (Ebert et al. 2009)

Changing smoking behaviour

Research has demonstrated that the most effective programmes are:

Social support (Walsh et al, 1997)

Rewards (Donatelle et al., 2000)

Shared planning of smoking cessation care using a woman-focussed approach (Ebert and Fahy, 2000)

Combined interventions (Ebert and Fahy, 2007)

Role of the midwifeMidwives have a public health role

Midwives see women over a prolonged periodPregnancy represents a ‘teachable moment’

(McBride, 2003)

Role of the midwife

Current guidelines for health professionals:

Ask (about smoking at every opportunity)

Advise (all smokers to stop)Assist (the smoker to stop)Arrange (follow up)

(Raw et al., 1998)

Changing smoking behaviour

Role of the midwife

Difficult to translate broad policy into specific support...NHS ‘Smokefree’ based around their own packs, telephone support and online toolsSpecific pregnancy area in website

www.smokefree.nhs.uk

Role of the midwifeGeneral support for women

START Plan

S = Set a quit date. T = Tell family, friends, and co-workers that you plan

to quit. A = Anticipate and plan for the challenges you'll

face while quitting.R = Remove cigarettes and other tobacco products

from your home, car, and work.T = Talk to your doctor about getting help to quit.

(US Surgeon General Office, 2009)

Role of the midwifeGeneral support for women

Talk to a supporter/friend Keep the house smoke free Keep the car smoke free Have the first cigarette later in the day Make the interval between cigarettes

longer Use the money saved for something

specific Call the NHS Helpline for support and

counseling (adapted from Viccars, 2008)

Think about the woman in the first

slide again...

What words would you use to describe

the image now?

Would you feel better equipped to offer

support?

Thank you!

Dr Catherine Angellcangell@bournemouth.ac.uk

Useful references

Baxter, S., Blank, L.,Guillme, L., Messina, J., Everson Hock, E., Burrows, J., (2009) Systematic review of how to stop smoking in pregnancy and following childbirth. London, NICE.

Briggs, G., Freeman, R., (2005) Drugs in Pregnancy and Lactation. Oxford, OUP.

Ebert, G., Fahy, K., (2007) Why do women continue to smoke in pregnancy? Women and Birth, 20 (1)

Ebert, L., Riet, P., Fahy, K., (2008) What do midwives need to understand/know about smoking in pregnancy. Women and Birth, 22 (1)

Lumley J, Oliver SS, Chamberlain C, Oakley L (2008) Interventions for promoting smoking cessation during pregnancy. The Cochrane Library. London, Wiley.

NHS (2009) Smoking in pregnancy. Available from www.smokefree.nhs.uk [accessed Jan 2010]