1. Tobacco, Alcohol and Drug Use in Childbearing Families Presented by: Dona Dei, RN/MSN ddei@marchofdimes.com

2. © 2007, March of Dimes Smoking and Pregnancy

3. © 2007, March of Dimes Substance Abuse During Pregnancy (SAMHSA, 2005) Based on data collected from surveys of U.S. households in 2003 and 2004: –18.0 percent of pregnant women reported that they smoked cigarettes. –11.2 percent drank some alcohol. –4.5 percent engaged in binge drinking. –0.5 percent engaged in heavy drinking. –4.6 percent used some kind of illicit drug.

4. © 2007, March of Dimes Pregnancy and Smoking 16.2 % of women smoke cigarettes Smoking is an important determinant of health status and a major contributor to prematurity, low birth weight and SIDS

5. © 2007, March of Dimes

6. Smoking Risks in Pregnancy Ectopic pregnancy Intrauterine growth restriction Placenta previa Abruptio placentae PROM Spontaneous abortion Preterm delivery SIDS (up to 4 times greater occurrence in smoking mothers )

7. © 2007, March of Dimes Smoking and Pregnancy Black smokers had substantially higher cotinine concentrations at all levels of cigarette smoking than White smokers. Caraballo, JAMA 280:135, 1998

8. © 2007, March of Dimes Smoking and Child Health

9. © 2007, March of Dimes Cost of Complicated * Births

10. © 2007, March of Dimes Substance Abuse During Pregnancy (SAMHSA, 2005) (Continued) Pregnant women are less likely to use substances than their peers. The exception is pregnant women aged 15 to 17; this substance use rate is 26 percent for pregnant women, compared with 19.6 percent for nonpregnant women.

11. © 2007, March of Dimes Smoking and Pregnancy Smoking during pregnancy is responsible for: –20% of all LBW –8% of preterm births –5% of all perinatal deaths Pregnant smokers compared to nonsmokers are: –2.0-5.0 times as likely to experience PPROM –1.2-2.0 times as likely to deliver preterm –1.5-10 times as likely to deliver a SGA infant –1.5-3.5 times as likely to deliver a LBW infant

12. © 2007, March of Dimes Substance Abuse During Pregnancy (SAMHSA, 2005) (Continued) Rates of substance abuse in pregnancy have stayed constant. Pregnant women’s tobacco use decreased from 2002 to 2004, while alcohol and illicit drug use increased (SAMHSA, 2005).

13. © 2007, March of Dimes Substance Abuse During Pregnancy (SAMHSA, 2005) Women more prone to substance abuse: –Earn below poverty level –Were exposed to violence as a child –Have a history of domestic abuse –Suffer depression or other mental health problems –Have less than a high school education –Are unmarried –Are unemployed –Are involved with the criminal justice system

14. © 2007, March of Dimes Substance Abuse During Pregnancy (SAMHSA, 2005) Substance use is highest in the first trimester. The most common form of substance use in pregnancy is smoking among White women. Because tobacco, alcohol and drug use in pregnancy occurs across all demographic groups, nurses should screen all women.

15. © 2007, March of Dimes The Problem of Addiction Addiction does not occur unless psychological and social conditions promote continued drug use. Nurses are better able to provide support and nonjudgmental care if they respect substance users as reasonable and intelligent persons whose judgment has been impaired.

16. © 2007, March of Dimes Genetic Contributions to Addiction The propensity to specific addictions has been linked to particular genes. Genetic differences may affect the seriousness of biological consequences of substance exposure in pregnancy.

17. © 2007, March of Dimes Addiction as a Biopsychosocial Problem Addiction is produced when biological, psychological and social predispositions combine with exposure to substances and an environment that supports regular substance use. Nursing assessment should focus on a broad scope of personal, familial and social stressors and coping skills.

18. © 2007, March of Dimes Women’s Treatment Issues Women may be more predisposed to addiction than men. Women are adversely affected by smaller amounts of alcohol and drugs than men. Women are more likely than men to lack resources to pay for drug treatment.

19. © 2007, March of Dimes Women’s Treatment Issues (Roberts & Dunn, 2003) (Continued) Women’s treatment programs must take a whole-life approach and address: –Low self-esteem –The need for social services and parenting support –Protection from violence –Training in relationship issues and coping skills –Vocational and legal assistance

20. © 2007, March of Dimes The 5 A’s 1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to make a quit attempt 4. Assist in quit attempt 5. Arrange follow-up

21. © 2007, March of Dimes Ethical Challenges A conflict exists between the woman’s right to autonomy over her body and behavior and the nurse’s sense of obligation to prevent harm to the fetus. If nurses are part of an enforcement system instead of advocates for women’s needs, women may avoid prenatal care and social services.

22. © 2007, March of Dimes The Nurse’s Role In prenatal and acute care settings, nurses should: –Thoroughly assess psychosocial risks –Conduct mutual goal-setting to minimize harm associated with psychosocial risks –Offer support and respect The sense of being valued can help drug users begin to make changes.

23. © 2007, March of Dimes Tobacco Use in Pregnancy: Maternal Effects Cigarette smoking is the most common form of substance abuse in pregnancy. It is linked to: –Decreased fertility –Spontaneous abortion –Placenta previa –Placental abruption –Ectopic pregnancy –Preterm premature rupture of membranes (PPROM) –Preeclampsia

24. © 2007, March of Dimes Tobacco Use in Pregnancy: Fetal Effects Impaired transfer of oxygen and nutrition Long-term cognitive function and increased risk of brain damage Chronic low-level hypoxia Intrauterine growth restriction (IUGR) Preterm delivery Low birthweight (LBW) in term infants

25. © 2007, March of Dimes Tobacco Use in Pregnancy: Neonatal Effects Impaired respiratory function in premature infants Low neurobehavior scores and higher withdrawal-symptom scores Asthma, respiratory illness and pneumonia Infections of the middle ear Increased risk of cancer and SIDS

26. © 2007, March of Dimes Introducing Social Issues The nurse should begin to explore the woman’s home situation, including: –Stress related to work, finances, family and pregnancy –Satisfaction with the amount and kind of support in her social network –Feelings about self-esteem and ability to cope with stressors

27. © 2007, March of Dimes Three-question Substance-use Screen Have you ever drunk alcohol? How much alcohol did you drink in the month before pregnancy? How many cigarettes did you smoke in the month before pregnancy?

28. © 2007, March of Dimes Substance Abuse Assessment In no case should urine or blood testing be used without consent. If a woman admits to substance abuse, testing is not needed to confirm the presence of a problem.

29. © 2007, March of Dimes Tobacco Use Assessment Women generally report their smoking status fairly accurately. The Fagerstrom Test for Nicotine Dependence is used to assess the level of addiction to tobacco (Heatherton et al., 1991).

30. © 2007, March of Dimes The Fagerstrom Test for Nicotine Dependence How soon after you wake up do you smoke your first cigarette? Do you find it difficult to refrain from smoking in places where it is forbidden? Which cigarette would you hate most to give up? How many cigarettes per day do you smoke? Do you smoke more frequently in the first hours after waking than during the rest of the day? Do you smoke if you are so ill that you are in bed most of the day?

31. © 2007, March of Dimes Principles of Brief Intervention: Problem Recognition and Goal-Setting 1.Provide feedback on problems, symptoms and historical events that suggest a substance abuse problem. Offer simple, realistic information about the effects on mother and baby. 2.Advise the woman to stop (or cut down) using substances. 3.Emphasize that any action taken is the woman’s choice. 4.Give options for treatment. 5.Get agreement from the woman on at least one action to take.

32. © 2007, March of Dimes Follow-up During Pregnancy and Postpartum At each visit, the nurse should: 1.Ask the woman about psychosocial issues. –Progress in reducing substance use –Use of treatment options –Health changes 2.Impart good news.

33. © 2007, March of Dimes Harm Reduction Harm reduction is an important principle for care of substance users (MacMaster, 2004). When abstinence is not achieved, reducing the harm of substance use is an important goal.

34. © 2007, March of Dimes Recognizing the Full Scope of the Problem Few substance users are able to quit on their first attempt. Nurses should view any progress as worthwhile and recognize that recovery is a lifelong process. Women need to develop entirely new social support systems.

35. © 2007, March of Dimes Smoking Treatment: Follow-up During Pregnancy One of the least expensive and most effective forms of follow-up is telephone contact. Follow-up should focus on how the effort is going; support and reinforcement for even small successes; suggestions to overcome obstacles; and health progress reports.

36. © 2007, March of Dimes Smoking Treatment: Reducing Postpartum Relapse Thirty percent to 70 percent of smokers who quit during pregnancy relapse by 1 year postpartum (Secker-Walker et al., 1998). Postpartum follow-up is essential. Nurses can offer the same tips they gave to pregnant smokers, with emphasis on planning ahead to avoid excessive fatigue and isolation.

37. © 2007, March of Dimes Summary Nurses can: –Provide life-changing interventions for vulnerable families –Advocate for increased funding for women’s substance-abuse treatment –Work to reduce harmful stigma –Advocate for healthy environments that reduce exposure to substances