1. Smoking Cessation for Pregnancy and Beyond: Virtual Clinic Companion Slides Catherine A. Powers, EdD, LSW PACE – Tobacco Prevention and Cessation Education for Medical School Students Boston University School of Medicine Funded by NCI R25-CA9 1958-04

2. Smoking Mortality and Morbidity in the United States Smoking is the single most preventable cause of deaths in the United States Smoking-related disease and complications account for 450,000 deaths each year in the United States It is estimated that between 12 and 20% of pregnant women in the US smoke Association of Women’s Health Obstetric and Neonatal Nurses, 2002; Martin, J.A., et al. Births: Final Data for 2002. National Vital Statistics Reports, volume 52, number 10, Dec. 2003.

3. Smoking and Women’s Unique Risks All smokers are at risk of heart disease, stroke, cancer and pulmonary disease Women have additional risks related to menstrual and reproductive functions - Increased risk of conception delay at primary and secondary infertility - Increased risk of ectopic pregnancy and spontaneous abortion - Earlier menopause with more severe symptoms US Department of Health and Human Services, The Health Consequences of Smoking: A Report of the Surgeon General (2004)

4. The Risks of Smoking During Pregnancy Premature rupture of the membranes Abruptio placentae Preterm delivery Smoking during pregnancy accounts for: 20% of Low birth weight babies 8% of pre-term deliveries 5% of prenatal deaths US Department of Health and Human Services, Surgeon General’s Report 2001: Women and Smoking

5. The Benefits of Quitting Women who quit smoking before or during pregnancy reduce the risk for adverse reproductive outcomes, including: conception delay infertility premature rupture of membranes preterm delivery low birth weight US Department of Health and Human Services, Surgeon General’s Report 2001: Women and Smoking

6. Quitting during Pregnancy A higher percentage of women stop smoking during pregnancy, both spontaneously and with assistance than at other times in their lives. Using pregnancy-specific programs can increase smoking cessation rates, which benefits infant health and is cost effective. Within 6 months of delivery women who quit smoking immediately after learning they are pregnant (spontaneous quitters) have a 70% relapse rate Smoking Cessation in Pregnancy: A Review of Postpartum Relapse Prevention Strategies J Am Board Fam Pract 17(4):264-275, 2004. US Department of Health and Human Services, Surgeon General’s Report 2001: Women and Smoking

7. Pharmacotherapy and the Pregnant Smoker The efficacy of nicotine replacement therapy in pregnancy is not known The only completed and published randomized controlled trial of nicotine replacement (delivered by transdermal patches) showed no difference from placebo, but the numbers studied were small, and the trial was underpowered to determine whether nicotine replacement was effective. Researchers did find that babies born to women in the nicotine treatment group had significantly higher birth weights than those in the placebo group indicating that the intrauterine growth restriction caused by smoking is probably not attributable to nicotine. More research is needed to determine the effects of nicotine replacement therapy on pregnant women and their offspring. ‘Nicotine replacement therapy in pregnancy’ BMJ 2004;328:965-966

8. Tobacco Cessation Programs Women are more likely than men to use intensive treatment programs. Women have a stronger interest than men in smoking cessation groups that offer mutual support through a buddy system and in treatment meetings over a long period. US Department of Health and Human Services, Surgeon General’s Report 2001: Women and Smoking

9. Smoking Cessation Groups There are two types of smoking cessation groups that are discussed in the literature Support groups also labeled self-help groups Group counseling with a trained facilitator

10. Support/Self-Help Groups and Group Counseling Support groups are more informal and require the client to be motivated to attend the meetings on her own Self-help does not appear to have a significant impact on reducing rates of smoking among the general population US Public Health Service Clinical Practice Guidelines, Treating Tobacco Use and Dependence, 2000 Group counseling may be done in a more structured environment, or even in a prenatal care setting It is organized by a health care professional with knowledge of evidence-based tobacco treatment approaches Facilitated group counseling improves people's ability to quit 14% abstinence rate vs. 10.8% no intervention

11. Intra-treatment and Extra Treatment Supportive Interventions Intra-treatment Interventions (within treatment setting) provider offers encouragement and belief in user's ability to quit Provider communicates caring and concern, is open to individual's expression of fears of quitting and ambivalent feelings Tobacco user is encouraged to talk about the quitting process (reasons to quit, previous successes, difficulties encountered) The use of intra-treatment social support yields a 14.4% abstinence rate (Fiore et al. 2000) Extra-treatment Interventions (outside treatment setting) Tobacco user is offered skills training in soliciting support from others (family, friends, co-workers), is helped in establishing a smoke-free home Help lines and web resources are available 1-800 QUIT NOW www.helppregnantsmokersquit.org Tobacco user can use a buddy system (letters, contracts, tip sheets) www.lungusa.orgwww.lungusa.org Extra-treatment social support yields a 16.2% abstinence rate (Fiore et al. 2000)