1. Smoking Cessation & Pregnancy Susan A. Albrecht, PhD, RN Donna D. Caruthers, PhD(c), RN University of Pittsburgh School of Nursing Supported by: National Institute of Nursing Research # RO1-NR03233

2. 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

3. Significance Adults 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 females Highest rates of smoking in pregnancy (26%) (Matthews, NVSS, 49:7, 2001)

4. Teen Smoking & Pregnancy Allegheny County, 1995 Age (Years) %

5. 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)

6. 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.)

7. 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.)

8. Fetus and Infant Health Risks Low birth weight Sudden Infant Death Syndrome (SIDS) Respiratory illnesses Pulmonary, Otitis Media, Asthma School problems Lower scores on spelling & reading tests Decreased attention Risk for hyperactive behavior Increased Hospitalizations (Pollack, H.A., Am J Public Health, 2001; 91(3) & ACOG Educational Bulletin, 1997;240.)

9. 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)

10. 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

11. 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

12. RCT- Adult Relapse Delivery %

13. Predictors of Relapse Adult Pregnant Smokers Dependence/Tobacco use Passive exposure (spouse) Not breast feeding Self-efficacy Education Tobacco Control 2000, 9; supplement

14. Another Approach Extending research to include pregnant teen smokers

15. 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.

16. Problem Behavior Theory Social Environment System Personality System Behavior System Perceived Environment System Adapted from Jessor, Donovan, & Costa (1991)

17. 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)?

18. 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).

19. 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).

20. 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

21. Data Collection Baseline – T1 Following 8 week intervention – T2 6 weeks postpartum – T3 1 year following baseline – T4

22. 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

23. 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)

24. 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%

25. Social Support for Quitting %

26. Other Baseline Problem Behaviors %

27. Ethnic Differences p <.001

28. Teen Fresh Start - Intervention Topics of group sessions 1-3: 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

29. Results – Following Intervention

30. Following Intervention p<.008

31. Results – 12 months Following Study Entry

32. Relapse – Baseline to 1 Yr.

33. Group, Carbon Monoxide, Booster CO level ppm n = 34

34. Group, Cotinine, Booster Cotinine level ng/ml n = 38

35. Predictors of Abstinence Predictor  SEpO.R.Conf. Interval Attitude Parent vs Peer.57.18.0021.771.2 – 2.5 Constant -5.031.17 Test of Model X 2 = 12.9, 3df, p <.005

36. Predictors of Abstinence Predictor  SEpO.R.Conf. Interval Attitude Parent vs Peer.44.21.0351.541.03 – 2.3 ETOH Pre- Pregnancy 1.7.78.0295.461.2 – 25.0 Constant -5.131.34 Test of Model X 2 = 11.9, 4df, p <.018

37. 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.

38. 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.

39. 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?