1. Smoking Cessation in Pregnancy Richard O. Davis, MD Department of OB/GYN Division Maternal Fetal Medicine University of Alabama at Birmingham

2. Objectives Discuss the adverse outcomes related to smoking in general Discuss the adverse outcomes related to smoking in general Discuss the adverse outcomes related to smoking during pregnancy Discuss the adverse outcomes related to smoking during pregnancy Discuss benefits of smoking cessation during pregnancy Discuss benefits of smoking cessation during pregnancy Discuss methods to achieve smoking cessation during pregnancy Discuss methods to achieve smoking cessation during pregnancy Discuss relapse rates and potential avenues of decreasing relapse Discuss relapse rates and potential avenues of decreasing relapse

3. The Culprit “Nicotina Tobacum” - “Discovered” by Columbus on trips to New World - “Discovered” by Columbus on trips to New World - Became widely popular in western Europe - Became widely popular in western Europe - Initially popular in snuff and cigars - Initially popular in snuff and cigars - Manufactured cigarette in 20 th Century - Manufactured cigarette in 20 th Century increased smoking increased smoking

4. The Facts Tobacco Related Disease (TRD) 21% of American adults smoke (44.5 million) 21% of American adults smoke (44.5 million) Each year, 440,000 Americans die of TRD Each year, 440,000 Americans die of TRD Accounts for 1 in every 5 deaths Accounts for 1 in every 5 deaths Ann Int Medicine 2006;145:839-44

5. The Facts Smoking Increased cardiovascular disease Increased cardiovascular disease Increased lung cancer Increased lung cancer –68,000 women die annually –Responsible for 1 in 4 cancer deaths in women –27,000 more deaths each year than breast cancer Public Health Service, Office of Surgeon General 2001

6. The Facts Initiation of Smoking Begins early during teenage years Begins early during teenage years 22% of U.S. high school students smoke 22% of U.S. high school students smoke Historically, male smoking rates greater than female Historically, male smoking rates greater than female In many countries, no sex difference in smoking rates In many countries, no sex difference in smoking rates Lancet 2006;367:749-53

7. Women Who Smoke High parity High parity Lesser education Lesser education Low economic status Low economic status Poor coping skills Poor coping skills Exposure to domestic violence Exposure to domestic violence Job strain Job strain

8. Cultural Influence Women Who Smoke Native American/Alaskan29% White (Non-Hispanic)20% Black (Non-Hispanic)17% Other18% Asian 5% MMWR 2004;53:427-51

9. The Facts Complications in Pregnancy Increased risk of ectopic pregnancy Increased risk of ectopic pregnancy Placenta previa Placenta previa Placenta abruption Placenta abruption Stillbirth Stillbirth Premature rupture of membranes Premature rupture of membranes Clin Obstet Gynecol 2008;51(2):419-35

10. Complications in Pregnancy The Likely Culprits Nicotine: vasoconstriction Nicotine: vasoconstriction –Fetal serum (15%) and amniotic fluid levels (88%) higher than maternal Carbon Monoxide: Diminished tissue oxygenation Carbon Monoxide: Diminished tissue oxygenation –Fetal levels higher (15%) than maternal Cyanide: Harmful to rapidly dividing cells Cyanide: Harmful to rapidly dividing cells –Cyanide levels are higher in smokers Clin Obstet Gynecol 2008;51(2):419-35

11. Complications in Pregnancy Other Toxic Compounds Ammonia Ammonia Polycyclic aromatic hydrocarbons Polycyclic aromatic hydrocarbons Vinyl chloride Vinyl chloride Nitrogen oxide Nitrogen oxide

12. Complications in Pregnancy (Heavy Smoking > 20 cigarettes/day) Low birthweight (<2500 g) (  200-300 g) Low birthweight (<2500 g) (  200-300 g) Preterm birth (OR 1.2 – 1.8) Preterm birth (OR 1.2 – 1.8) Smoking accounts for 5% of prenatal deaths and 20-30% of low birthweight deliveries Smoking accounts for 5% of prenatal deaths and 20-30% of low birthweight deliveries Clin Obstet Gynecol 2008;51(2):419-35

13. Maternal Life Time Smoking Complications Atherosclerotic disease Atherosclerotic disease Lung cancer Lung cancer COPD COPD Increased risk of ectopic pregnancy Increased risk of ectopic pregnancy Premature menopause Premature menopause Infertility Infertility Osteoporosis Osteoporosis

14. Infants, Children and Secondhand Smoke Increased Risks Respiratory infections Respiratory infections SIDS SIDS Asthma/bronchitis Asthma/bronchitis Short stature Short stature Hyperactivity Hyperactivity Decreased school performance Decreased school performance Clin Obstet Gynecol 2008;51(2):419-35

15. Smoking Cessation Interventions Higher proportion of women stop during pregnancy than at any other time in their lives Higher proportion of women stop during pregnancy than at any other time in their lives 20-30% of smoking women attempt to stop 20-30% of smoking women attempt to stop About 40% who stop do so before their first OB visit About 40% who stop do so before their first OB visit Factors: Concern for effects on baby; nausea and vomiting Factors: Concern for effects on baby; nausea and vomiting Cochrane Database Sys Rev 2005

16. Challenges and Barriers to Cessation Need to be acknowledged by patient and provider Need to be acknowledged by patient and provider Most smokers make several attempts to quit Most smokers make several attempts to quit Discuss reasons for past failures Discuss reasons for past failures Successful smoking cessation is associated with continuous patient education and assessment Successful smoking cessation is associated with continuous patient education and assessment The 5 A’s and 5 R’s (endorsed by ACOG and National Cancer Institute and British Thoracic Society) for patients unable or reluctant to quit The 5 A’s and 5 R’s (endorsed by ACOG and National Cancer Institute and British Thoracic Society) for patients unable or reluctant to quit Clin Obstet Gynecol 2008;51(2):419-35

17. The 5 A’s Ask: Query with multiple choice questions, document Ask: Query with multiple choice questions, document Advise: Urge tobacco users to quit Advise: Urge tobacco users to quit Assess: Determine willingness to quit Assess: Determine willingness to quit Assist: Provide aid and choose quit date Assist: Provide aid and choose quit date Arrange: Provide follow-up contact. Congratulate success. Consider referral or more intensive treatment and potential pharmacotherapy Arrange: Provide follow-up contact. Congratulate success. Consider referral or more intensive treatment and potential pharmacotherapy

18. The 5 R’s Relevance: Identify motivational factors Relevance: Identify motivational factors Risk: Stress the acute and long-term risks of smoking Risk: Stress the acute and long-term risks of smoking Reward: Ask/Help patient identify benefits to her and her family Reward: Ask/Help patient identify benefits to her and her family Road blocks: Identify barriers and impediments Road blocks: Identify barriers and impediments Repetition: Repeat motivational intervention and visit Repetition: Repeat motivational intervention and visit

19. Smoking Cessation Intervention Why During Pregnancy? Genuine concern for baby Genuine concern for baby Frequent physician/provider visits Frequent physician/provider visits Only time some women seek medical care Only time some women seek medical care Likely to experience high levels of social and family support for quitting Likely to experience high levels of social and family support for quitting

20. Smoking Cessation Programs Shown to be helpful compared with no intervention Shown to be helpful compared with no intervention Tobacco dependence treatments are clinically useful and cost effective Tobacco dependence treatments are clinically useful and cost effective Cochrane Database Sys Rev 2005 JAMA 2000;283:3244-254

21. Successful Smoking Cessation Prevent up to 5% of perinatal deaths Prevent up to 5% of perinatal deaths Prevent up to 20-30% of low birthweight births Prevent up to 20-30% of low birthweight births Prevent up to 15% of preterm births Prevent up to 15% of preterm births Am J Obstet Gynecol 2005;192:1856-1862

22. Smoking Cessation in Pregnancy Smoking has greatest impact in third trimester Smoking has greatest impact in third trimester Encourage smoking cessation throughout pregnancy Encourage smoking cessation throughout pregnancy Women who quit by third trimester have birthweights similar to non-smokers Women who quit by third trimester have birthweights similar to non-smokers Am J Public Health 1994;84:1127

23. Role of Counseling Meta Analysis Brief, intense counseling 5-15 minutes Brief, intense counseling 5-15 minutes –Cessation rate 5%-10% Brief counseling and pregnancy specific educational printed material Brief counseling and pregnancy specific educational printed material –Cessation doubles to about 20%

24. Cost Effectiveness of Smoking Cessation For every $1 for successful cessation, $3.3 are saved on treating shorten neonatal morbidities (NICU) For every $1 for successful cessation, $3.3 are saved on treating shorten neonatal morbidities (NICU) Ratio of savings increase to 6:1 when long-term care and morbidity are considered Ratio of savings increase to 6:1 when long-term care and morbidity are considered Until further evidence based conclusions are made, brief cognitive behavioral interventions accompanied by pregnancy-specific self-help materials are most effective intervention for pregnant smokers. Until further evidence based conclusions are made, brief cognitive behavioral interventions accompanied by pregnancy-specific self-help materials are most effective intervention for pregnant smokers. Individual Counseling for Smoking Cessation Cochrane Database Sys Rev 2005

25. Nicotine Replacement Therapy RCT by Wisborg et al showed that nicotine patches did not affect cessation rate, but did increase BW RCT by Wisborg et al showed that nicotine patches did not affect cessation rate, but did increase BW –Under-powered –Low compliance RCT by Oncken et al demonstrated that nicotine gum had no effect on cessation rate RCT by Oncken et al demonstrated that nicotine gum had no effect on cessation rate –Significantly reduced smoking –Increased EGA and BW at delivery Pollak et al showed NRT increased cessation rate by 3- fold, but there was increased adverse outcomes in this group Pollak et al showed NRT increased cessation rate by 3- fold, but there was increased adverse outcomes in this group Wisborg et al. 2000. Obstet Gynecol 96:967-971. Oncken et al. 2009. Obstet Gynecol 112:859-867. Pollack et al. 2007. Am J Prev Med 33:297-305.

26. Bupropion Aminoketone that is a weak reuptake inhibitor of dopamine, norepinephrine, and serotonin initially utilized as an antidepressant Aminoketone that is a weak reuptake inhibitor of dopamine, norepinephrine, and serotonin initially utilized as an antidepressant In non-pregnant adults, multiple studies have shown that bupropion significantly improves smoking cessation rates In non-pregnant adults, multiple studies have shown that bupropion significantly improves smoking cessation rates Case-control study including ~6K in each group by Alwan et al showed infants with cardiac defects were more likely to have been exposed to bupropion than controls (AOR 2.6; 95% CI 1.2- 5.7) Case-control study including ~6K in each group by Alwan et al showed infants with cardiac defects were more likely to have been exposed to bupropion than controls (AOR 2.6; 95% CI 1.2- 5.7) 3 other studies showed no association 3 other studies showed no association Hurt et al 1997. NEJM 337:1195-1202 Alwan et al 2010. Am J Obstet Gynecol 203:52e.1-6. Chun-Fai-Chan B et al 2005. Am J Obstet Gynecol 192:932-6.

27. U.S. Department of Health and Human Services Clinical Guidelines 2008 Pregnant women should be actively counseled and provided information regarding benefits of smoking cessation Pregnant women should be actively counseled and provided information regarding benefits of smoking cessation Smoking cessation in early pregnancy is preferred, but cessation at any time is beneficial Smoking cessation in early pregnancy is preferred, but cessation at any time is beneficial

28. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) Treating Tobacco Use and Dependence: 2008 Update No recommendation regarding medication use during pregnancy No recommendation regarding medication use during pregnancy NRT is probably safer than nicotine exposure from cigarettes NRT is probably safer than nicotine exposure from cigarettes Inconclusive evidence that cessation medications boost abstinence rates in pregnant smokers Inconclusive evidence that cessation medications boost abstinence rates in pregnant smokers

29. Postpartum Period and Relapse 50%-90% relapse within first year after delivery 50%-90% relapse within first year after delivery No proven strategies to prevent relapse No proven strategies to prevent relapse Continue encouragement, enforce benefits of cessation, reinforce patient’s desire to be a good mother Continue encouragement, enforce benefits of cessation, reinforce patient’s desire to be a good mother