RCN TOBACCO POLICY ADVISOR European representative to ICN and TFI/WHO Supporting Pregnant women to stop smoking JENNIFER PERCIVAL RCN TOBACCO POLICY ADVISOR European representative to ICN and TFI/WHO

Every midwife has seen a premature birth due to the effects of maternal smoking in pregnancy

BARRIERS TO DISCUSSING SMOKING DURING PREGNANCY EXPRESSED BY PROFESSIONALS Fear of damaging the relationship with the woman Lack of time Concern that smoking cessation knowledge and skills are insufficient Doubts about the effectiveness of advice Lack of good resources to back-up counselling Assuming a colleague has dealt with the issue Intermittent contact with individual women

Health professionals need to know.. Facts about Tobacco control How to link a persons health problems to their smoking history How to make effective brief interventions In the UK this is not yet included in basic training. Without training staff can rely on their own experiences which can be very negative …….

THIS ADVERT WAS USED IN THE 1950’S

TOBACCO ADVERTISING HAS ENCOURAGED WOMEN TO START

WOMEN WHO SMOKE DURING PREGNANCY have a 27% higher chance of a miscarriage increase by one third the risk of perinatal mortality are 3 times more likely to have a low birthweight baby (on average 200grms or around 7oz lighter) are more likely to have children who suffer breathlessness and wheezing in the first 6 months of life

Will not like me or let me care for them Staff attitudes to the topic of smoking Myth No.1 If I ask about my patient’s smoking habits they: Will not like me or let me care for them Will think I don’t understand or am judging them Will not return for their antenatal care Will not let me visit their home

Many nurses who smoke believe that: Staff attitudes to the topic of smoking if they smoke themselves Many nurses who smoke believe that: It would be hypocritical to talk to patients about stopping smoking In countries where nurses have a high rate of smoking this will have a negative impact on them making helpful interventions

UK Research showed smoking is often a pregnant woman’s assertion of herself Quotes: “I care more than anything about this child. I’ve stopped drinking, I eat more healthily now. I smoke because it’s something for me.”  Smoking is a way of signifying control over your life. Continuing to smoke preserves the pregnant woman’s precious self-esteem.

I’ve tried giving up before but I can’t do it. WHAT TYPE OF THINGS DO WOMEN SAY WHEN YOU ASK ABOUT SMOKING IN PREGNANCY? My last baby was ok. I’ve tried giving up before but I can’t do it. I enjoy it - I don’t want to give up. Nothing works for me. I’m more stressed when I try to stop. I use it for weight management. I have cut down a lot. I don’t smoke that many a day. My partner smokes so it’s really hard to give up. I’ll have a smaller baby so the birth will be easier. I’m not having any health problems so why should I stop. I get cheap fags so can afford it. I can’t be bothered to try and I don’t think it’s a problem. All my family smoke.

WHAT WORKS DURING PREGNANCY?

RAISING THE ISSUE Remember that most smokers expect to be asked about their smoking. The research shows that pregnant women want convincing evidence of the harm done and practical advice on stopping. IF THE ISSUE IS NOT ADDRESSED MANY WILL ASSUME THAT SMOKING DURING PREGNANCY IS OK.

Non-smoker Recent Ex Smoker Congratulate her Tell her not smoking is an excellent choice for herself and her baby Ask if she is planning to stay a non smoker after delivery?

Current smoker Assess motivation to change by asking the following questions How many packs do you smoke a day? Have you tried to stop smoking in the past year? Are you interested in stopping now you are pregnant?

A DIFFICULT TIME

A COMMITTED SMOKER Elicit what the pregnant smoker already knows and her interest in receiving information Explain the link between smoking and possible complications in pregnancy Provide all information neutrally Check out the woman’s ongoing decision and her interpretation of your discussion

THINKING ABOUT STOPPING? Check her understanding of the health risks and benefits of stopping Take a carbon monoxide reading Seeing the measurements of expired CO will give her objective information and can be very motivating Encourage her to believe she can succeed in stopping if she really wants to.

‘CUTTING DOWN’ IS OFTEN SEEN AS AN ACCEPTABLE COMPROMISE Often this is in response to nagging Means of reduction include switching from high tar and buying standard length. Exonerates her from further efforts. Take up can rise in response to stress. In practice they cheat themselves on amount smoked and make an insignificant reduction Women should be encouraged to quit rather than reduce consumption.

Making plans to quit? Congratulate this decision and offer your support or referral to specialist Recommend they use a treatment product Help them decide a date Check their expectations of quitting Ask ‘What could get in your way and What can you do to help yourself?

DURING THE PREGNANCY Show a continued interest and follow up the subject at each visit. Record the number of cigarettes smoked. Reinforce the benefits to the baby from her stopping.

RELAPSE Why do some smokers fail to quit? Stopping under pressure from someone else Lack of personal motivation Attaching insufficient importance to stopping Withdrawal symptoms Poor timing A question of self-image “I thought `just one’ wouldn’t hurt”

NICOTINE REPLACEMENT THERAPY NRT products licensed for use in UK since early 1980s NRT is generally very safe and much safer than continued use of nicotine from cigarettes Nicotine is a vasoconstrictor, so should be used with caution in those at high risk of acute cardiovascular events, unless the alternative is continued smoking. As with all drugs, NRT is better avoided in pregnancy, but again likely to be safer to mother and child than continued smoking. Shorter acting products may be better in pregnancy since they probably minimise fetal exposure 30

The pregnant women who are most likely to succeed at quitting are those who have: Thought about stopping for some time before becoming pregnant. Health concerns for the baby Been prepared for withdrawal symptoms An action plan for stopping which they have written down A coping strategy for critical times Support at home or friends to help them stop smoking No major stress occurring in their lives A willingness to return for follow up appointments

PROTECTING CHILDREN FROM SECONDHAND SMOKE

SMOKE FREE HOMES

HOW CAN YOU PROTECT CHILDREN FROM HARM? You can protect children by keeping their playing, sleeping and eating areas completely smoke-free. Always try to smoke outdoors or away from children. What if that’s not possible for me? Open a window or door when smoking and blow the smoke outside.