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9/17/2008 10:19:21 AM
Tobacco Dependency
in Women
the Reproductive Years
Jorge J. Garcia MD
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Miami
Miller School of Medicine
Disclaimer
 I have no financial relationship with any
pharmaceutical company
 I have no financial relationship with any company
involved in the production, advertisement ,
distribution, or sale of any tobacco products
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Acknowledgement
 This presentation is made possible through the
support of:

South Florida Area Health Education Center
 University of Miami Miller School of Medicine
Department of Family Medicine
Department of Obstetrics and Gynecology
Learning Objectives
Upon completion of this continuing education
activity, participants will be able to:
 Understand the global tobacco epidemic
 Describe the risks associated with the use of tobacco
products particularly in the context of pregnancy
 Employ evidence-based guidelines for smoking
cessation during pregnancy
 Recognize when to use pharmacologic intervention
 Establish a smoking cessation program in the
practice setting
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Tobacco Use Is One Of The
Biggest Public Health Threats
The World Has Ever Faced
 Almost half of the world's children breathe air
polluted by tobacco smoke.
 Tobacco use kills 5.4 million people a year - an
average of one person every six seconds - and
accounts for one in 10 adult deaths worldwide.
 It is a risk factor for six of the eight leading causes of
deaths in the world.
Global Causes of Death
5
4.5
D e a th s in M illio n s
4
3.5
3
2.5
2
1.5
1
0.5
0
Tobac
co
Lower
Respi
ra
D iarrh
Perin
T uber
atal C
culo si
eal Di
onditi
seases
s
to ry In
ons*
*
fectio
ns*
A ID S
* WHO World Health Report 2002
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Global Deaths
8
10
7
millions of deaths
Currently:
 4.9 million people die
per year
 13,400 people per day
 560 people every hour
By 2030:
 10 million people a
year will die from
tobacco use
 70% of those deaths
will occur in
developing countries
6
5
4
4.9
3
2
1
0
2000
2030
Developed Countries
Developing Countries
10
NY TIMES, 2/24/08
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Current Smoking Among Adults by State, 2005
•The percentage of all adults in each state/area who reported having smoked >100 cigarettes during their lifetimes
and who currently smoke every day or some days.
•Source: BRFSS, 2005.
Cigarette Smoking in FL
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Current Use of Various Tobacco Products
among Adults, by Sex—United States, 2000
35
31.3
Males
Females
30
25.7
25
Percent
21.3
21.0
20
15
10
4.5
5
0.2
1.0 0.1
Any Use Cigarettes Cigars
Pipes
2.5
2.5
0.2
0.1
0.1 0.1
0
Snuff
Chewing
Tobacco
Bidis
Note: Current users report using either every day or on some days
Source: National Center for Health Statistics
Per-Capita Consumption of Different
Forms of Tobacco in The U.S. 1880-2005
Pounds of Tobacco Per-Capita
14
12
10
Snuff
8
6
4
2
Chewing
Pipe/roll
your own
Cigarettes
Cigars
0
1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census
Note: Among persons >18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.
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Trends in cigarette smoking* among adults aged
>18 years, by sex - United States, 1955-2004
% CURRENT SMOKERS
60
50
Men
40
30
Women
23.4%
20
18.5%
10
0
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
YEAR
*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who
currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100
cigarettes during their lifetime and who reported now smoking every day day or some days.
Source: 1955 Current Population Survey; 1965-2004 National Health Interview Surveys.
20
Cigarette Smoking* Among Adults by
Gender—United States, 1955-2004
60
50
Males
Percent
40
30
20
Females
10
0
1955
1960
1965
1970
1975
1980
Year
1985
1990
1995
2000
Source: 1955 Current Population Survey; 1965-2002 NHIS
*Estimates since 1992 include some-day smoking
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Adult Per Capita Cigarette Consumption and Major
Smoking-and-Health Events—United States, 1900-2005
5,000
1st Surgeon
General’s Report
3,000
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
2,000
1st SmokingCancer Concern
Federal Cigarette
Tax Doubles
1,000
Great Depression
0
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
Source: USDA Tobacco & Situation Outlook report, 2005 ;1986-2000 Surgeon General's Reports
The good news is…
most smokers want to quit
90% regret ever having started to smoke
89% plan to quit; only 3% don’t want to quit
89% believe health will improve if quit
84% have tried to quit in the past
27% try to quit each year…
2004/2005 Assessing Hard Core Smoking Survey of US smokers ages 25+ years (n = 1,000)
Percentage of Ever Smokers* Who Have Quit, Adults
Aged > 18 Years, by Sex-United States, 1965 - 2004
60
51.4%
50
49.7%
40
Percent
Men
30
Women
20
10
2003
1999
2001
1997
1995
1993
1987
1989
1991
1985
1983
1981
1979
1977
1975
1973
1969
1971
1967
0
1965
Number of Cigarettes
4,000
Year
Source: National Health Interview Surveys, 1965-2004;
Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and
Health.
*Ever-smoked >100 cigarettes,
Also known as the quit ratio. Note: estimates since 1992 incorporate same-day smoking
24
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Current Cigarette Smoking by
Race/Ethnicity—United States, 1978-2004
70
African
American
60
American
Indian
Percent
50
40
Asian
30
Hispanic
20
White
10
0
19781980
19831985
19871988
19901991
19921993
19941995
19971998
19992000
200120032002
2004
Year
Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data
Current Cigarette Smoking: Hispanic/Latino
Adults, 1999-2001
60
50
Percent
40
30.4
30
22.8
21.3
20
23.1
19.2
10
0
Puerto Rican
Mexican
Central or
South American
Cuban
Overall
Source: National Survey on Drug Use and Health, 1999-2001
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Age in Years
Average Age First Cigarette Use by
Race/Ethnicity, 1999-2001
24
22
20
18
16
14
12
10
8
6
4
2
0
18.8
14.8
15.5
American White
Indian/
Alaska Native
15.7
15.9
Hawaiian Mexican
16.1
16.4
16.6
17.1
Korean
African
American
Puerto
Rican
Chinese
Asian
Indian
Source: National Survey on Drug Use and Health, 1999-2001.
Rate is the number of persons in the age group who initiate (first use) use of the drug in specified year
Cigarette Smoking by Education, Ages 25+—
United States, 1966-2004
60
<12
12
13-15
16+
% Current smokers
50
40
30
20
10
0
1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1997 2000 2003
Education (yrs)
Source: 1966-2004 National Health Interview Surveys
*Estimates since 1992 incorporate some-day smoking
Current Cigarette Smoking: GLBT Adults
 Prevalence ranged from 25 – 50 % in gay and bisexual
men
 Prevalence ranged from 11- 50% in lesbian and
bisexual women
Sources:
Ryan, et al - Am J Prev Med, 2001:21(2): 142-149
Tang, et al – Cancer Causes & Control, 2004, Oct 15(8):797-803
Dilley et al – Letter to editor, Cancer Causes & Control, 2005, Nov 16(9):1133-4
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SMOKING AMONG CHILDREN
AND ADOLESCENTS
Current Cigarette Smoking* by Grade in School—
United States, 1975-2006
45
12th Grade
10th Grade
8th Grade
40
35
Percent
30
21.6
25
20
14.5
15
8.7
10
5
0
1975197719791981198319851987198919911993199519971999200120032005
Year
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project, 2005
*Smoking 1 or more cigarettes during the previous 30 days
Current Cigarette Smoking* among 12th Graders
by Race—United States, 1977-2006
50
45
White
Black
Hispanic
40
Percent
35
30
25
20
15
10
5
0
1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005
Year
Source: Institute for Social Research, University of Michigan, Monitoring the Future Project, 2005
*Smoking 1 or more cigarettes during the previous 30 days
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Current Cigarette Smoking among Youth: GLBT
 38% for youth with same gender sexual experience
 59% for students who self-identified as lesbian, gay
and bisexual youth
Source: Ryan, et al - Am J Prev Med, 2001:21(2): 142-149
Current* Tobacco Use† Among Middle and High
School Students, 2004
50
Percent
40
Middle School
High School
28.2
30
22.5
20
13.3
11.6
9.8
10
6
3.5
5.9
3.5 3.2
2.4 2.6
Pipes
Bidis
2
2.7
0
Any Use † Cigarettes
Cigars
Smokeless
Kreteks
* Used tobacco on ≥ 1 of the 30 days preceding the survey
† Use of cigarettes, smokeless, cigars, pipes, Bidis, or Kreteks
Source: National Youth Tobacco Survey, 2004
Initiates/1,000 never smokers
Incidence of Initiation of Any Cigarette Use—
United States, 1965 -2003
160
120
12 to 17
80
18 to 25
40
0
1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003
Year
1
The numerator of each rate is the number of persons in the age group who initiated use of the drug in the specified year,
while the denominator is the person-time exposure of persons in the age group measured in thousands of years..
2 Estimated using 2003 and 2004 data only. 3 Estimated using 2004 data only.
3 Estimated using 2004 data only
Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002, 2003, and 2004..
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Initiation Rates among White Males by Birth
Cohorts, by Age—United States, 1900-1975
Percent
1900
1910
1920
1930
1940
1950
1960
1970
1975
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
Age
INFLUENCES ON TOBACCO USE AMONG
RACIAL/ETHNIC GROUPS
Smoking Patterns among African Americans
 African Americans tend to start smoking later and
smoke fewer per day
 Most likely to smoke higher tar and nicotine brands
 Most likely to smoke mentholated cigarettes
 Higher serum cotinine levels
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Socio-cultural Factors Influencing Smoking
Rates among Native Americans
 Important to distinguish between sacred uses and
addictive use
 Reliance on revenue from tobacco sales (reservations
tax exempt, internet sales)
 Smoking prevalence seems to vary less by SES in
Native Americans than other groups
Socio-cultural Factors Influencing Smoking
Rates among Asian and Pacific Islanders
 Age
 Gender
 Place of birth
 Level of acculturation
Socio-cultural Factors Influencing Smoking
Rates among Hispanics
 Country of origin
 Level of acculturation
 English speaking
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Socio-cultural Factors Influencing Smoking
Rates among GLBT Populations
 Daily stress due to homophobia
 Important social focus on places where smoking
is prevalent (bars)
 Alcohol and drug use may be higher
 Tobacco industry targeting
Thanks! Questions??
Contact info:
Mike Boysun
Phone number: 360-236-3671
Email: mike.boysun@doh.wa.gov
Tobacco Use in the United States
April, 2007
Mike Boysun
Epidemiologist and Evaluation Coordinator
Tobacco Prevention and Control Program
Washington State Department of Health
Slides adapted from presentation by:
Corinne G. Husten, MD, MPH
CDC, OSH
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Current Cigarette Smoking by Race/Ethnicity—
United States, 2003-2004
50
African
American
Percent
40
36.3
American
Indian
30
Asian
22.4
20.8
20
15.7
Hispanic
White
11.5
10
0
Source: National Health Interview Surveys, 2003 and 2004, aggregate data
1982 SURGEON GENERAL’S
REPORT
“Cigarette smoking is the
major single cause of cancer
mortality in the United
States”
Cigarettes kill more
Americans than alcohol,
car accidents, suicide,
AIDS, homicide and
illegal drugs combined
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All Tobacco Is Toxic!
 4000 chemicals in a cigarette
 Tar & toxins – black & sticky
 CO burns and displaces oxygen throughout the body
 Burning process breaks up the toxins
 Toxins heat up & release gases
 When you draw on the cigarette it passes these gases
into the lungs
 Heart works harder, devastates the cilia
Carbon Monoxide & Your Blood
 CO is a colorless, odorless, tasteless gas that is part
of the air we breathe
 Many sources of carbon monoxide such as
incinerators, car exhaust fumes and gas furnaces
 When the level of CO in your body increases, the
ability of your blood to carry oxygen is decreased
 Smoking increases the amount of CO in your blood
Adverse Health Effects of Smoking
 Cancers
 Cardiovascular diseases
– Lung
– Coronary heart disease
– Laryngeal, pharyngeal, oral
cavity, esophagus
– Stroke
– Pancreatic
– Bladder and kidney
– Cervical and endometrial
– Gastric
– Acute myeloid leukemia
 Reduced fertility in women, poor
pregnancy outcomes, low birth weight
babies, sudden infant death syndrome
– Abdominal aortic aneurysm
 Respiratory diseases
– Acute respiratory illnesses, e.g.,
pneumonia, otitis media, asthma
– Chronic respiratory diseases (COPD)
 Cataract
 Periodontitis
 Diabetes (2-fold increased incidence)
– (Diabetes Care 28:10 Oct 2005)
U.S. Department of Health and Human Services. The Health Consequences of Smoking:
A Report of the Surgeon General, 2004.
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 Smoking increases the risk for many types of
cancer:
– Lip
– Mouth
– Bladder
– Kidney
– Esophagus
– Lung
– Larynx (voice box)
– Pancreas
– causes coronary heart
disease
– doubles risk for stroke
– can cause chronic diseases:
• bronchitis
• COPD
• asthma
• high blood pressure
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Environmental Tobacco Smoke (ETS)
 Second-hand tobacco smoke is dangerous to health.
 It causes cancer, heart disease and many other serious
diseases in adults.
 Almost half of the world's children breathe air polluted by
tobacco smoke, which worsens their asthma conditions and
causes dangerous diseases.
 At least 200 000 workers die every year due to exposure to
second-hand smoke at work.
More About Tobacco Use









Tobacco use causes more premature deaths in the United States than any other
preventable risk.
If current patterns of smoking behaviors continue, an estimated 6.4 million of today's
children can be expected to die prematurely from smoking-related illnesses.
Cigarette smoking increases coughing, shortness of breath, and respiratory illnesses;
decreases physical fitness; and adversely affects blood cholesterol levels.
Smoking cigars increases the risk of oral, laryngeal, esophageal, and lung cancers.
Smokeless tobacco is not a safe alternative to cigarettes. Using it causes cancers of the
mouth, pharynx, and esophagus; gum recession; and an increased risk for heart
disease and stroke.
Light cigarettes are not healthier than regular cigarettes.
Secondhand smoke puts children in danger of developing severe respiratory diseases
and can hinder the growth of their lungs.
Exposure to secondhand smoke as a child or adolescent may increase the risk of
developing lung cancer as an adult,7 or worsen existing asthma.
Tobacco use causes stained teeth, bad breath, and foul-smelling hair and clothes.
The Dollars in the US
Direct Medical Costs
$260 million
Lost productivity due to death
$270 million
Average US smoker spends per year
on cigarettes
$1600
Tobacco industry spending on
marketing and promotion
$13.4 billion (2005)
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Major Sources of Data on Tobacco
Use in the United States
 Consumption Data
— U.S. Department of Agriculture (USDA)
 Surveys of Adults
— National Health Interview Survey (NHIS)
— National Survey on Drug Use and Health (NSDUH)
— National Health and Nutrition Examination Survey
(NHANES)
— Behavioral Risk Factor Surveillance System (BRFSS)
— Current Population Survey (CPS)
— Adult Tobacco Survey (ATS)
Major Sources of Data on Tobacco Use
in the United States
 Surveys of Youth
— Monitoring the Future Surveys (MTFS)
— Youth Risk Behavior Surveillance System (YRBSS)
— National Survey on Drug Use and Health
(NSDUH)
— National Health and Nutrition Examination Survey
(NHANES)
— Teenage Attitudes and Practices Surveys (TAPS)
— National Youth Tobacco Survey (NYTS)
— Youth Tobacco Survey (YTS)
National Surveys
 National Health Interview Survey (NHIS)
 Current Population Survey (CPS)
 National Survey on Drug Use and Health (NSDUH)
 Monitoring the Future Survey (MTFS)
 Youth Risk Behavior Survey (YRBS)
 National Youth Tobacco Survey (NYTS)
 Birth Certificate Vital Statistics
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State-specific Surveys
 Behavioral Risk Factor Surveillance System
(BRFSS)
 Current Population Survey (CPS)
 Youth Tobacco Survey (YTS)
 Pregnancy Risk Assessment Monitoring System
(PRAMS)
 Adult Tobacco Survey (ATS)
 Vital Statistics (birth, death)
U.S. Output of Fine Cut Tobacco and
Snuff, 1950-2005
100
90
Million pounds
80
70
60
50
40
30
20
10
0
1950 1954 1958 1962 1966 1970 1974 1978 1982 1986 1990 1994 1998 2002
Source: USDA Tobacco & Situation Outlook report, 2005 ;1986-2000 Surgeon General's Reports
U.S. Output of Small and Large Cigars,
1950 to 2005
Begin advertising
little cigars
12
10
Ban Advertising of Little Cigars
SGR
Total consumption
Billions
8
Cigar Aficionado
Large cigars
and cigarillos
6
4
Small cigars
2
0
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
Year
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Prevalence of Smoking among White Males by
Birth Cohorts, by Age—United States, 1900-1980
1900
1910
1920
1930
1940
1950
40 45
Age
50
1960
1970
1980
80
70
Percent
60
50
40
30
20
10
0
5
10
15
20
25
30
35
55
60
65
70
75
80
Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987; Burns et al. 1997.
Prevalence of Smoking among White Females by
Birth Cohorts, by Age—United States, 1900-1980
1900
1910
1920
1930
1940
1950
40 45
Age
50
1960
1970
1980
80
70
Percent
60
50
40
30
20
10
0
5
10
15
20
25
30
35
55
60
65
70
75
80
Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987; Burns et al. 1997.
Get with the guidelines
David Brown, MD
Family Medicine & Community Health
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5
TOBACCO
HISTORY
WHY DO WE
SMOKE?
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Addiction Facts
Cigarette addiction is a 3-part
Phenomenon
 Physical addiction – as evidenced by the
biochemical changes in the brain
 Physiological addiction- becoming reliant on it to
do for “us” what we think we can’t, and use it to
bus us time and distract others from us
 Habit- smoke 60% of our cigarettes because of an
environmental or behavior trigger
Working Class Women are target of mass marketing
campaigns by tobacco companies
RJR - Winston
USA
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Carrie Nation (WCTU founder) - 1890s
These tobacco users transmit nervous
diseases, epilepsy, weakened
constitutions, depraved appetites and
deformities of all kinds to their
offspring.
The tobacco user can never be the
father of a healthy child.
ETS
exposure!
”Smoking behaviour of women differs from that of
men…more highly motivated to smoke…they find it
harder to stop smoking…women are more neurotic
than men…there may be a case for launching a
female oriented cigarette with relatively high
deliveries of nicotine”
1976 Research Report
British American Tobacco
Recruiting Women Smokers - the Origin of the Problem
1926 - don’t
be left out!
1929 - avoid
getting fat
1934 - cures
depression and
tiredness!
1932 - must
be good for
your health!
1942 - it’s
patriotic to
smoke!
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Targeting Women — Taking Aim at Minorities
Current Ads in Women’s Magazines
The Tobacco
Industry DOES
market to women
Prince: Caines
Czech Republic
There are
approx. 250
million women
addicted to
tobacco
worldwide
PM: L & M
Czech Republic
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“Selling tobacco products to women
currently represents the single
largest product marketing
opportunity in the world.”
Kaufman and Nichter 2001
Altadis: Gauloise
England & Qatar
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Tobacco companies have
not produced a range of
brands aimed at women.
Most notable are the
”women-only” brands:
those feminised cigarettes
are long, extra slim, low
tar, light coloured or
menthol.
B&W - Lucky Strike
Czech Republic
Women’s tobacco use is an
international issue with complex
dimensions and implications
Manhattan
Peru
www.trinketsandtrash.org
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www.trinketsandtrash.org
http://roswell.tobaccodocuments.org/bar_promos/camel_promo1/index.htm
“Blow some
my way”
“Superslim Capri
means less smoke for
those around you”
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The tobacco
industry has years
of advertising
experience – and a
big budget
PM - Chesterfield
USA - 1949
6 TOBACCO
ADDICTION
HABIT
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TOBACCO: FRIEND OR FOE?
 Effects of Tobacco on Health
 All Tobacco is Toxic!
 Carbon Monoxide and Your Blood
 Pharmacological Treatments
 Quit Tobacco in the House
and in the Car
 Preparing for Quit Day
 One Dozen Decisions
Effects Of Tobacco on Health
Every day, people suffer from illnesses caused by
the effects of their smoking or from exposure to
second-hand or environmental tobacco smoke.
What are
the events
Avoiding
Triggers
that trigger
or activities
you to smoke?
Review possible triggers and
possible solutions on pages 52-53
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HALT
 Feelings of hunger, anger,
loneliness and
fatigue may
serve as triggers to return
to smoking/tobacco use
 Two-thirds (67%) of people
return to
smoking when
they experience any
of the
above feelings for long
periods of time
 Research studies show that the nicotine in cigarettes
Nutrition
Exercise
is
responsibleand
for increasing
your metabolic rate
 Due to the higher metabolic rate when smoking, the
ex-smoker now has a lower metabolic rate and burns
100 to 200 fewer daily calories
 Nicotine can serve as an appetite suppressant—many
people rely on that fact to keep their weight down.
TOBACCO
and
PREGNANCY
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SMOKING DURING PREGNANCY
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Cigarette Smoking During Pregnancy—
United States, 1989-2004
25
20
Percent
20
15
10.2
10
5
0
1989
1991
1993
1995
1997
1999
2000
2002
2003
2004
Note: Percentage excludes live births for mothers with unknown smoking status.
Sources: National Center for Health Statistics 1992, 1994; Ventura et al. 1995, 1997, 1999, 2000; Martin et al. 2002, 2003.
Prevalence of Smoking During Pregnancy, PRAMS
Prevalence of Smoking Before and D uring Pregnancy, PR AMS
2001-2004
Before
During
25
21.3
20
19.7
21.8
19.5
Percent
15
10.6
10
9.4
10.0
9.8
5
0
2001
2002
2003
2004
Source: Florida’s Increasing Prevalence of Smoking During Pregnancy: The
Impact of Revising the Birth Certificate ,Angel Watson, MPH, RHIA, Florida
Department of Health
34
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Multiple Determinants of
Children’s Health
 Genetic
 Social
 Environmental
 Disease conditions
 Medical care
 Health Systems
 Politics/Economics
Tobacco and Child Health
 Smoking impacts children through:
prenatal exposure
environmental tobacco smoke
teen smoking
 Direct medical cost of all pediatric disease
attributable to parental smoking$7.9 billion dollars
 $13.76 billion in loss of life
 15% reduction in parental smoking could save
$1 billion in direct medical costs
CDC-1999
35
9/17/2008 10:19:21 AM
Smoking Harms Every Phase of Reproduction*
Before Pregnancy, women who smoke
 have more difficulty becoming pregnant and
 have a higher risk of never becoming pregnant.
Source: Centers for Disease Control
http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece/page5.htm
Smoking Harms Every Phase of Reproduction
During pregnancy, nicotine freely crosses
the placenta and has been found in
amniotic fluid and the umbilical cord blood
of newborn infants. (It is found in breast
milk too.)
Source: American Cancer Society
http://www.cancer.org/docroot/PED/content/PED_10_2x_Smoke
less_Tobacco_and_Cancer.asp?sitearea=PED
 Maternal smoking associations:
– Effects during Pregnancy
• Low Birth Weight (growth retardation)
– Effects in Infancy
• Increased SIDS
– Effects in Childhood and Adolescence
• Increased hyperactivity (ADHD)
• Increased alcohol & drug use as adolescent
• Decreased child IQ
• Increased asthma
36
9/17/2008 10:19:21 AM
SMOKING DURING PREGNANCY
THE SINGLE MOST PREVENTABLE CAUSE OF ILLNESS AND
DEATH
INthan
MOTHERS
AND
INFANTS
 Smokers are more
likely
nonsmokers
to have
a miscarriage or
ectopic pregnancy.
 Babies born to smokers are 1.5–3.5 times more likely to have low birth
weight
 Low-birth weight babies are at risk for serious health problems
throughout their lives.
 Up to ¼ of low birth weight births could be prevented by eliminating
smoking during pregnancy.
 Up to 8% of all babies who die less than a week after birth do so
because of problems caused by their mothers’ smoking during
pregnancy.
 The risk for sudden infant death syndrome (SIDS) increases three-fold
for mothers who smoke during and after pregnancy and two-fold for
mothers who smoke only after delivery.
 Smoking during pregnancy increases the risk of stillbirth by 40 to 60
percent.
Smoking during Pregnancy
 Higher risk of gestational diabetes
 5 to 6 % of perinatal deaths
Smoking during Pregnancy
 7 to 10 percent of preterm deliveries
 Asthma - 25% higher rate in children whose mother
smoked less than 10 cigarettes per day
– 36% higher in children whose mothers smoked
more than 10 cigarettes per day.
Tobacco Use During Pregnancy Maternal Harm
Possible causal association
-placenta previa
-spontaneous abortion
Probable causal association
-ectopic pregnancy
-preterm PROM
Causal association
-abruptio placenta
37
9/17/2008 10:19:21 AM
Tobacco Use During Pregnancy Infant Harm
Causal association
-low birth weight
-small for gestational age
-preterm delivery
-Sudden Infant Death
Syndrome (SIDS)
-stillbirths
Harms of Tobacco Exposure
during Infancy and Early
Childhood
Causal association
-otitis media
asthma
-new and exacerbated cases
of
-bronchitis and pneumonia
-wheezing and lower
respiratory illness
Adolescent Smoking
 Nearly all smokers begin as adolescents
 75% become daily smokers by 20 y.o.
 Higher daily consumption, lower quit rate
 Female > Male
 Affective and Cognitive Components
 Vulnerable subset: loss of autonomy with a few cigs
also - greater withdrawal problems
 Relationship to maternal smoking during pregnancy?
38
9/17/2008 10:19:21 AM
Risks to Children Who have
Mothers that Smoke
 More likely to be hospitalized
during the first two years of life
Risks to Children Who Have
Mothers that Smoke
SUDDEN INFANT DEATH SYNDROME
RISK
NEARLY TRIPLES
WITH MATERNAL SMOKING
DURING AND AFTER PREGNANCY
Effects of Prenatal Tobacco Exposure
Across Periods of Development
SIDS
SIDS
VERBAL/
LEARNING
DEFICITS
INATTENTION
ADHD
CRIMINAL
OFFENSES
LOW BIRTHWEIGHT/
PREMATURITY
ATTENTION
DEFICITS
CONDUCT
DISORDER
ASPD
STARTLES &
TREMORS
EXTERNALIZING
BEHAVIORS
SMOKING
UPTAKE
NICOTINE
DEPENDENCE
Infancy
Childhood Adolescence
Adult
39
9/17/2008 10:19:21 AM
Annual Smoking-Related Child
Morbidity and Mortality
Maternal Smoking During Pregnancy Increases
Risk of Offspring Behavior Problems
 1-2 day old infants - elevated scores on measures of stress
and excitability
 Toddlers - at increased risk for aggressive behavior,
negativity and hyper activity
 Teenagers - at risk for memory problems and other
cognitive difficulties. cognitive difficulties
and an increase in risk for cigarette addiction during
adolescence.
Environmental Tobacco Smoke (ETS)
During Pregnancy
 Children of mothers who smoked during pregnancy
were found to have thicker walls around the
carotid arteries- making them more susceptible
to stroke and heart attack. This damage appears
to be PERMANENT
Journal of Epidemiology, August 2007
40
9/17/2008 10:19:21 AM
Prenatal secondhand smoke exposure worsens
ADHD, aggressive behaviors, and poor school
performance in these children
Child Psychiatry and Human Development, May 23, 2007
Environmental Tobacco Smoke (ETS)
 6,200 children die annually in the US directly related to
their parent’s smoking
2,800 from LBW complications
2,000 from SIDS
1,100 from Respiratory Infections
250 from Burns
Asthma (smaller number)
 56% higher chance of being hospitalized in the 1st
year of life
 The level of secondhand smoke a child is exposed
to at home or in a work environment is directly
proportional to the child becoming a smoker
41
9/17/2008 10:19:21 AM
42
9/17/2008 10:19:21 AM
Percent of pregnant women who reported smoking during
pregnancy on the birth certificate, Annually
12
10
7.49
7.83
7.42
Percent
8
7.07
6
4
2
0
2004
2005
2006
2007 Year to Date
Want More Information on the Effects of
Tobacco Exposure during Pregnancy?
Go to
 Dept. of Health website at
http://www.doh.state.fl.us/Family/mch/Substan
ceAbuse/Tobacco/tobacco.html
 The Health Consequences of Involuntary Exposure
to Tobacco Smoke: A Report of the Surgeon
General, 2006
http://www.surgeongeneral.gov/library/secondha
ndsmoke/
43
9/17/2008 10:19:21 AM
HEALTHY START
Standards & Guidelines
Standard 10.1
 All providers receiving Healthy Start funding to provide
prenatal care will ask about tobacco use, advise to quit,
assist in quit attempt, arrange follow-up, and advise about
the dangers of ETS to the pregnant woman, those in her
home, and to infants.
44
9/17/2008 10:19:21 AM
45
9/17/2008 10:19:21 AM
46
9/17/2008 10:19:21 AM
Smoking During Pregnancy by Race/Ethnicity—
United States, 1989-2003
40
African
American
Percent
30
American
Indian
Asian
20
Hispanic
White
10
0
1989
1991
1993
1995
1997
1999
2001
2003
Year
Source: National Center for Health Statistics, 2004
Smoking during Pregnancy, by Asian
or Pacific Islander*—United States, 1989-2002
40
Percent
30
Hawaiian and Part Hawaiian
Filipino
Chinese
Japanese
Other Asian or Pacific Islander
20
10
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Year
*Determined by the origin of mother
Source: National Center for Health Statistics
47
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48
9/17/2008 10:19:21 AM
Tobacco Cessation
Evidence Based
Interventions
49
9/17/2008 10:19:21 AM
Prenatal Care Provider Tools for
Tobacco Cessation Counseling
 ACOG model-Smoking and Pregnancy: A Clinician’s
Guide to Helping Pregnant Women Quit Smoking.
2002
 Treating Tobacco Use and Dependence: A Clinical
Practice Guideline. UNITED States Department of
Health and Human Services. Public Health Service.
June 2000
Effective Interventions
for Tobacco Cessation
● Counseling (individual, group, quitlines)
● Pharmacotherapy (6 FDA approved medications)
● Reducing patient out-of-pocket costs (insurance coverage)
● Physician intervention – 5A’s
Advise, Asses, Assist, Arrange)
(Ask,
● Increasing the unit price of tobacco products
● Smoking bans and restrictions
● Mass media campaigns
● Reminder systems (for clinical settings)
Integrated Approach to Tobacco
Cessation
Government
Purchaser
Cessation
Programs
Health
Systems/
Insurers
Tobacco
User
Private
Purchasers
Providers/
Clinicians
QUITLINE
50
9/17/2008 10:19:21 AM
5A’S
Treating Tobacco Use & Dependence
 Surgeon General
recommended “5 A’s”
approach
Source:
http://www.surgeongeneral.gov/
tobacco/clinpack.html
Clinical Practice Guidelines for Brief tobacco cessation
Counseling
5 A’s =Make Yours a Fresh Start Family
Ask
Advise
Assess
Assist
Arrange
=
Survey
=
Tailor health message
=
Assess
=
Give materials & plan
=
Evaluate progress at
followup
6
51
9/17/2008 10:19:21 AM
Ask






Identify and document tobacco use
for every participant at every visit
Identify smokers and recent quitters
Determine possible barriers to
quitting
Identify other smokers in the home
22
Step 1:

Survey = Ask
Identify and document tobacco use for every
participant at every visit
-Can ask participant to choose the statement that best
describes them
a. I have never smoked or have smoked less than 100
cigarettes in my life.
b. I stopped smoking before I found out I was
pregnant, and I am not smoking now.
c. I stopped smoking after I found out I was pregnant,
and I am not smoking now.
d. I smoke some now, but I have cut down since I
found out I was pregnant.
e. I smoke regularly now, about the same as before I
found out I was pregnant.
Source: The American College of Obstetricians and
Gynecologists, Smoking Cessation during Pregnancy
tent card.
22
Advise
 Acknowledge the difficulty of quitting
 Give information about the effects of smoking
 on the fetus, child, smoker
 Stress benefits of quitting – relate to motivations
 person may have mentioned
 Give clear recommendation to quit
 Positively reinforce recent quit attempts/success at
 quitting
22
52
9/17/2008 10:19:21 AM
 Only 70% of family physicians currently
ask their patients if they use tobacco.
 Only 40% take further action.
– -AAFP
 Too busy
 Lack of expertise
 No financial incentive
 Expect futility
AEB1
 Don’t want to appear judgmental
 Respect for patient’s privacy
 Negative message might scare patients
away
 Health professional smokes
 70% of smokers see a physician each year.
 70% of smokers want to quit.
AEB2
 Patients are more satisfied with their health
care if their provider offers smoking cessation
interventions - even if they’re not yet ready to
quit.
53
Slide 158
AEB1
aafp
Amy Bannister, 12/13/2005
Slide 159
AEB2
aafp
Amy Bannister, 12/13/2005
9/17/2008 10:19:21 AM
“As your healthcare provider, I
have to tell you that quitting
smoking is one of the most
important things
you can do for your health.”
Assess
 Offer help
 Ask if willing to try to quit
 Build confidence in ability to quit
162
54
9/17/2008 10:19:21 AM
Assess: Key Questions
 Are You Interested in Quitting
With My/Our Assistance?
 Are You Ready to Quit in the Next 4-6
Weeks?
163
The Process of Behavior Change
Preparation
Action
Contemplator
Maintenance
Pre-contemplator
Relapse
Ex-Smoker
164
 PRECONTEMPLATION - NOT READY TO THINK
ABOUT CHANGE
55
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CONTEMPLATION - Will listen to new information and
consider the idea of changing behavior - moves
slowly toward change.
PREPARATION - Taking a series of steps toward
quitting including setting a quit date. ABOUT TO
LEAP INTO CHANGE.
 ACTION - The first day one stops tobacco use, and
the daily struggle over the next few months to
maintain cessation.
56
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MAINTENANCE - sustains cessation over a period
of time
RELAPSE - part of the recovery process in
addiction
- when old behavior returns, use learned behavior
change skills that worked
HOOKED AGAIN
Risk Factors for Smoking Cessation Relapse
After Pregnancy
Elizabeth Clark, MD, MPH (1,2)
Kenneth D. Rosenberg, MD, MPH (1, 3)
(1) Oregon Health & Science University, Portland,
Oregon
(2) University of Iowa College of Medicine, Iowa
City, Iowa
(3) Oregon DHS Office of Family Health, Portland,
Oregon
9th Annual Maternal and Child Health
Epidemiology Workshop, Tempe, AZ
December 10, 2003
57
9/17/2008 10:19:21 AM
Assist
PURPOSE:
 To Assist client
 To help the client take positive action toward quitting
which is appropriate to her readiness to quit
 This step provides the foundation for further follow-up
and reinforcement
172
Give Materials: Key Notes







Give support
Offer the appropriate handouts and review
Assist with developing a plan of action
Discuss pharmacotherapy
Make appropriate referrals (Quitline, groups, etc.)
Optional materials
Follow-up appointment if possible
173
Arrange





Praise positive steps
Rephrase initial messages where needed
Direct to appropriate pages in materials
Build motivation
Document status & next steps planned
174
58
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2 A’s + R
3 MINUTE VERSION
 ASK – every patient about tobacco use and
document in their medical record – 1 minute
 ADVISE – urge every tobacco user to quit; employ
the teachable moment and link visit findings with
advice – 1 minute
 REFER – patients to quitline or cessation classes
and document in medical record – 1 minute
Patients Who Decline to Quit: Using the
5 R’s
Relevance
Risks
Rewards
Roadblocks
Repetition
5 R’s: Relevance
 Ask patient to identify why quitting might be
personally relevant, such as:
– children in her home
– need for
money
– history of
smokingrelated illness
59
9/17/2008 10:19:21 AM
5 R’s: Risks
 Ask, “What have you heard
about smoking during
pregnancy?”
 Reiterate benefits for her
unborn baby and her other
children
 Tell her that a previous
trouble-free pregnancy is
no guarantee that this
pregnancy will be the
same
5 R’s: Rewards
 Your baby will get more
oxygen after just 1 day
 Your clothes and hair will
smell better
 You will have more
money
 Food will taste better
 You will have more
energy
5 R’s: Roadblocks
 Negative moods
 Being around other
smokers
 Triggers and cravings
 Time pressures
60
9/17/2008 10:19:21 AM
Overcoming Roadblocks:
Negative Moods
 Suck on hard candy
 Engage in physical activity
 Express yourself (write, talk)
 Relax
 Think about pleasant, positive
things
 Ask others for support
Overcoming Roadblocks:
Other Smokers
 Ask a friend or relative to quit with you
 Ask others not to smoke around you
 Assign nonsmoking areas
 Leave the room when others smoke
 Keep hands and mouth busy
Overcoming Roadblocks:
Triggers and Cravings
 Cravings will lessen within a few weeks
 Anticipate “triggers”: coffee breaks, social
gatherings, being on the phone, waking up
 Change routine—for example, brush your teeth
immediately after eating
 Distract yourself with pleasant activities: garden,
listen to music
61
9/17/2008 10:19:21 AM
Overcoming Roadblocks:
Time Pressures
 Change your lifestyle to reduce stress
 Increase physical activity
tobacco cessation during
Pregnancy: Postpartum
Maintenance
Up to 35% of women who stop
smoking during pregnancy
remain nonsmokers, benefiting:
 Woman’s health
 Next pregnancy
 Child’s health
Results:
Risk Factors for Relapse
 Among the women who quit smoking during pregnancy,
risk factors for relapse (Odds Ratio, 95% CI):
Bivariate
Multivariate
– Living with other smokers
7.65)
3.32 (1.38, 8.00)
3.13 (1.28,
– Multiparous
5.58)
2.60 (1.10, 6.14)
2.28 (0.94,
– Medicaid (at L&D)
2.24 (0.96, 5.23)
– Unmarried
1.83 (0.78, 4.32)
– Black race
1.55 (0.63, 3.80)
– Teen mother (<20 yrs)
0.86 (0.31, 2.40)
62
9/17/2008 10:19:21 AM
 Half of smoking women successfully quit
smoking during pregnancy
 60% of women who quit smoking during
pregnancy were still quit at time of survey
 Women who lived with other smokers were less
likely to stay quit
 We
Living
found
with
that
other
living
smokers
with is
other
thesmokers
strongest
is
the strongest
risk
factor for
risk
relapse.
factor for relapse.
 Programs to decrease smoking among pregnant
women should include partners
 Women are more likely to stay quit for their
first baby than for subsequent babies.
 Pregnant women who are internally motivated
to quit (for themselves) are more likely to
stay quit postpartum than women who are
externally motivated to quit (for their
baby)*
*Stotts AL et al. Pregnancy smoking cessation: a case of
mistaken identity. Addictive Behaviors. 1996;21;459-471.
63
9/17/2008 10:19:21 AM
Public Health Implications
 More federal support for programs that help pregnant women
quit and stay quit.
 Women who live with other smokers need extra social support
to quit and stay quit.
 Replicate 5As Screening for prenatal care providers: Ask,
Advise, Assess, Assist, Arrange [www.smokefreefamilies.org].
 Use of 5As can cause lower relapse rates at one year
postpartum.*
*Secker-Walker RH, et al. Amer J Prev Med;1998:25-31
Forever Free...For Baby and Me: A Guide to Remaining
Smoke Free
“up to 70% relapse after they give birth”
 Moffitt Cancer Center developed 10 booklets
 for pregnant and postpartum women
 based on previous research and interviews with women
 includes a booklet for the woman’s partner
 pilot testing Spanish version
 http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD
1417520E2D9B85

Source: http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD1417520E2D9B85
64
9/17/2008 10:19:21 AM
Smoking Cessation
Cost Savings
$ Cost of intervention
$24-$34
$ Neonatal cost savings $881
per maternal smoker
Source: Costs of a tobacco cessation Counseling Intervention for Pregnant
Women: Comparison of Three Settings, Ayadi, Et al, pages 120-126, Public
Health Reports / March–April 2006 / Volume 121.
HEALTHY
START
Tobacco Cessation Services Provided
– To reduce the incidence of prenatal and postpartum tobacco use
– To reduce the incidence of tobacco use by all
household members
– To reduce exposure of the pregnant woman, fetus
and infant to environmental tobacco smoke
HEALTHY START
Standards & Guidelines
Standard 10.3
 The Healthy Start participant’s stage of readiness
for change (based on Prochaska and DiClemente’s
Stages of Change Model) will be reviewed during
each tobacco cessation service in order to offer
the appropriate service.
65
9/17/2008 10:19:21 AM
Standards&Guidelines
Minimum Components of Counseling
Criteria 10.6.d include
– Consequences of tobacco use
– Nicotine addiction
– Pharmaceutical products available for
tobacco cessation
– Side effects and contraindications
– Reasons for quitting
– Breastfeeding education for tobacco
users
HEALTHY START
Standards & Guidelines
Minimum Components of Counseling
Criteria 10.6.d include
– Awareness of habits associated with tobacco
use
– Stress reduction methods
– Exercise and nutrition
– Relapse and relapse prevention
– Appropriate disposal
– Danger of smoking while
HEALTHY START
Standards & Guidelines
Pharmaceutical Aids*

Nicotine patch

Nicotine gum

Nicotine nasal spray

Nicotine inhaler

Bupropion SR (Zyban)

Lozenge
*Unless contraindicated
66
9/17/2008 10:19:21 AM
Standard 10.10: Tobacco cessation service providers will develop and
implement an internal quality improvement and quality assurance
process
 Develop QI/QA process with coalition
– Strengths and areas needing improvement
– Maintenance of quality/ improvement
– Participant satisfaction
– Participant behavioral changes
– Reduction or elimination of tobacco use
– Rate of post-delivery relapse
– Positive health and developmental outcomes
HEALTHY START
Standards & Guidelines
Some Factors to Remember
 Treatable
 Cycles of relapse and remission
 Requires ongoing management, just like diabetes
or hypertension
 Person requires counseling, support, and,
possibly, pharmacotherapy
 Clinicians must recognize relapse is common
Are the 5A's Enough?: Tobacco Dependence
Treatment for Smokers with Mental Illness
National Conference on Tobacco or Health
October 25, 2007
67
9/17/2008 10:19:21 AM
From CDC Best Practices, 2007
Preventive Services’ Guide to Community Preventive Services
recommends:
 Increasing the unit price of tobacco products
 Conducting mass media education campaigns when combined
with other community interventions
 Mobilizing the community to restrict minors’ access to tobacco
products when combined with additional interventions (stronger
local laws directed at retailers, active enforcement of retailer
sales laws, retailer education with reinforcement)
 Implementing school-based interventions in combination with
mass media campaigns and additional community efforts
CDC Guidelines for School Health Programs to Prevent Tobacco Use and
Addiction
An updated version of the guidelines scheduled for release in 2008. Latest available is 1994
(
 Develop and enforce a school on
tobacco use that establishes
environments that are tobaccoat all times, including off-site
events.
 Provide a sequential tobacco-use
prevention curriculum during K–
12, with intensive delivery in
junior high or middle school,
with reinforcement in high
school
)

Provide instruction that covers physiologic
and social consequences of tobacco use,
social influences tobacco use, peer norms
regarding tobacco use, and skills that
promote tobacco-free lifestyle.


Provide program-specific training teachers.
Involve parents, families, and community in
support of school based programs to prevent
tobacco use.

Provide support for tobacco-use cessation
efforts among students school staff who use
tobacco.

Assess the tobacco-use prevention program
at regular intervals.
RTIPS: The only tested and approved programs for clinical and
school settings









1. Title: It's Your Life - It's Our Future
Purpose: Smoking cessation program designed for American Indians in California
2. Title: Kentucky Adolescent Tobacco Prevention Project
Purpose: Designed to prevent tobacco use among adolescents living in high tobacco production areas.
3. Title: LifeSkills Training
Purpose: Emphasizes personal and social skills development related to general life skills and substance abuse.
4. Title: Not-On-Tobacco Program (N-O-T)
Purpose: Designed to promote cessation and reduce tobacco use among adolescent smokers.
5. Title: Pathways to Health
Purpose: School-based cancer prevention and health promotion program for 5th and 7th grade American Indian students.
6. Title: Physician Counseling Smokers (PCS) Program
Purpose: Office-based program designed to increase the effectiveness of primary care physician -delivered smoking cessation
interventions
7. Title: Project Towards No Tobacco Use (TNT)
Purpose: School-based prevention project designed to delay the initiation and reduce the use of tobacco by middle -school children.
8. Title: Sembrando Salud
Purpose: Designed to improve parent-child communication skills as a way of improving and maintaining healthy youth decision making.
9. Title: Spit Tobacco Intervention
Purpose: Designed to promote cessation and reduce initiation of spit tobacco use among male high school athletes.
68
9/17/2008 10:19:21 AM
CLINICAL PRACTICE GUIDELINES
The Clinical Practice Guidelines provide specific
recommendations regarding brief and intensive
tobacco cessation interventions as well as
system-level changes designed to promote the
assessment and treatment of tobacco use. Brief
clinical approaches for patients willing and
unwilling to quit are described.
http://www.surgeongeneral.gov/tobacco/smokesum.htm
9
CONTEMPLATION
69
9/17/2008 10:19:21 AM
Risk Factors for Smoking Cessation Relapse
After Pregnancy
Elizabeth Clark, MD, MPH (1,2)
Kenneth D. Rosenberg, MD, MPH (1, 3)
(1) Oregon Health & Science University, Portland,
Oregon
(2) University of Iowa College of Medicine, Iowa
City, Iowa
(3) Oregon DHS Office of Family Health, Portland,
Oregon
9th Annual Maternal and Child Health
Epidemiology Workshop, Tempe, AZ
December 10, 2003
Introduction
 Maternal
Maternalsmoking
smokingassociations:
associations:
– –Effects
Effectsduring
duringPregnancy
Pregnancy
• •Low
LowBirth
BirthWeight
Weight(growth
(growthretardation)
retardation)
– –Effects
EffectsininInfancy
Infancy
• •Increased
IncreasedSIDS
SIDS
– –Effects
EffectsininChildhood
Childhoodand
andAdolescence
Adolescence
• •Increased
Increasedhyperactivity
hyperactivity(ADHD)
(ADHD)
• •Increased
Increasedalcohol
alcohol& &drug
druguse
useasasadolescent
adolescent
• •Decreased
Decreasedchild
childIQIQ
• •Increased
Increasedasthma
asthma
Public Health Implications
 More federal support for programs that help pregnant women
quit and stay quit.
 Women who live with other smokers need extra social support
to quit and stay quit.
 Replicate 5As Screening for prenatal care providers: Ask,
Advise, Assess, Assist, Arrange [www.smokefreefamilies.org].
 Use of 5As can cause lower relapse rates at one year
postpartum.*
*Secker-Walker RH, et al. Amer J Prev Med;1998:25-31
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Nicotine, Tobacco and Brain Damage,
From the Fetus to the Adolescent:
Finding the Smoking Gun
Theodore Slotkin, Ph.D.
Dept. of Pharmacology & Cancer Biology
Duke University Medical Center
Research Support: NIH DA14247 and the Philip Morris External Research Program
U.S. Annual Figures for Maternal Cigarette Smoking
Overall US Rate: 10-20% of all births
•Spontaneous abortions:
•Low Birthweight:
•Neonatal ICU Admissions:
•Perinatal Deaths:
19,000
32,000
14,000
1,900
- 141,000
- 61,000
- 26,000
4,800
•50-500% Increased Incidence of:
•SIDS
•Learning Disorders
•ADHD
•Disruptive Behaviors
DiFranza et al, J. Fam. Pract. 1995
 ETS exposure: part of the continuum of adverse effects
 Fetal nicotine range ≈ 10-30% of active smoking
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Maternal Cigarette Smoking
Nicotine in Fetus
Maternal-Fetal Unit
Hypoxia/Ischemia
CO, HCN
Anorexia
Effects on Fetal Brain
General Development
Perinatal Morbidity/Mortality
Growth Retardation
Behavioral Anomalies
Risky Behaviors:
Other drugs/alcohol
Prenatal Care
Socioeconomic
Adolescent Nicotine Effects
 Greater Sensitivity of ACh and Serotonin systems
• enhanced onset of nAChR upregulation and greater persistence
• persistent deficiency in synaptic activity - ACh and Serotonin
• exquisite sensitivity - down to level of ‘chipper’ or ETS
 Cell damage
• loss of synaptic function
• brain areas involved in learning and memory, mood
 Sex selectivity: effects on females > males (also true for adolescent smokers)
Conclusion: There is a biological basis for the
susceptibility of the adolescent brain to nicotine addiction
2000 PHS Clinical Practice Guidelines

Clinicians and health care delivery systems (including administrators,
insurers, and purchasers) should institutionalize the consistent
identification, documentation, and treatment of every tobacco user seen
in a health care setting.

There is a strong dose-response relation between the intensity of tobacco
dependence counseling and its effectiveness.
–
–

Brief tobacco dependence treatment is effective and every patient who
uses tobacco should be offered at least brief treatment.
Treatments involving person-to-person contact (via individual, group, or
proactive telephone counseling) are consistently effective, and their
effectiveness increases with treatment intensity (e.g., minutes of
contact).
Three types of counseling and behavioral therapies are effective and
should be used with all patients attempting tobacco cessation:
– Provision of practical counseling (problem solving/skills training);
– Provision of social support as part of treatment (intra-treatment
social support); and
– Help in securing social support outside of treatment (extratreatment social support).
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10 5 R’S
TREATMENTS
BEHAVIORAL
NRT
Smoking Cessation if more cost-effective
than other commonly provided clinical
preventive services, including
mammography, colon cancer screening,
PAP smears, hypertension treatment and
treatment of high cholesterol
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 Smoking is the most modifiable risk factor for poor birth
outcomes
 Successful treatment of tobacco dependence can achieve:
– 20% reduction in low–birth-weight babies
– 17% decrease in preterm births
– Average increase in birth weight of 28 g
Source: Lumley J, Oliver S, Waters E. Interventions for promoting tobacco
cessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055.
Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stop
smoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy.
American College of Obstetricians and Gynecologists. ACOG Educational
Bulletin Number 260. September 2000.
Conclusions from Behavioral
Intervention Studies
 Pregnancy is a good time to intervene
 Brief counseling works better than simple advice
to quit
 Counseling with self-help materials offered by a
trained clinician can improve cessation rates by
30% to 70%
 This brief intervention works best for moderate
(<20 cigarettes/day) smokers
44% of FL Women Smokers Atttempted to
Quit in 2003
Note: Every Day Smokers who
quit smoking cigarettes
for >1 day during the past
year.
Source: Behavioral Risk
Factor Surveillance System
(BRFSS)
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Reasons to Quit
 Avoid tobacco-related illnesses
 Save money
 Improve physical and athletic performance
 Live a healthier life
 Improve your sense of smell and taste
 Improve circulation
 Feel better about oneself
 Stop worrying about quitting
 Be in control, finally, not the cigarette
 Set a good example for children
Benefits of Quitting
 Many times those who have smoked for a
long time do not realize that they can
improve their health by quitting
 This is a good time to reiterate this to
them
 Review benefits on page 31
Barriers to Quitting
 Almost ALL smokers erect barriers, these are back doors that
they leave open that will keep them from quitting
 Here are some of the roadblocks that keep people from
quitting:
I’ll gain too much weight
I’ve cut down already
My spouse will make it hard for me
My friends will offer me cigarettes
Too much stress in my life
I will get irritable when I quit
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Timing of Health Benefits
20 minutes
Blood pressure, heart rate return to
normal
8 hours
O2 level returns to normal; nicotine
and CO levels reduced by half
2 to 12 weeks
Circulation improves
3 to 9 months
Lung function increases by up to
10%; coughing, wheezing,
breathing problems reduced
24 hours
CO is eliminated from body; lungs
begin to eliminate mucus, debris
1 year
Heart attack risk halved
48 hours
Nicotine eliminated from body; taste
and smell improve
10 years
Lung cancer risk halved
72 hours
Breathing is easier; bronchial tubes
relax; energy levels increase
15 years
Heart attack risk same as for
someone who never smoked
1990 Surgeon General’s Report
226
Call to Action
 Smoking is the most modifiable risk factor for poor birth
outcomes
 Successful treatment of tobacco dependence can achieve:
– 20% reduction in low–birth-weight babies
– 17% decrease in preterm births
– Average increase in birth weight of 28 g
Source: Lumley J, Oliver S, Waters E. Interventions for promoting tobacco
cessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055.
Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stop
smoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy.
American College of Obstetricians and Gynecologists. ACOG Educational
Bulletin Number 260. September 2000.
 Set a quit date
 Tell/enlist family & friends
 Anticipate withdrawal / cravings / triggers
 Prepare environment
 Offer pharmacotherapy
 Provide support through the office
 Schedule follow up
 Intensive Counseling
 Quit line
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Counseling/Behavioral Therapies
Counseling should include at least four 30minute sessions (face-to-face or via telephone)
which
– Provide practical counseling that includes problem
solving and skills training
– Teach individuals to enlist outside support from friends,
family and co-workers
– Provide individual, group or telephone counseling,
focusing on person-to-person support
– Follow-up counseling should be included for recent
quitters (less than one year) to prevent relapse
Smoking Cessation
Evidence-based clinical guidelines on cessation
conclude that:
brief advice by medical providers to quit
smoking is effective
more intensive interventions (individual, group,
or telephone counseling) that provide social
support and training in problem solving skill
are even more effective
FDA approved phamacotherapy can also help
people quit smoking, particularly when
combined with counseling and other
interventions
 Many pregnant smokers are highly
dependent and so find it hard to quit
 NRT is not a magic cure
 Intensive behavioral support is crucial;
to helping pregnant smokers to stop
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Adverse effects of
nicotine are
probably influenced
by: DOSE, RATE and
ROUTE of delivery
Safety of NRT
 Cannot be said without risk because it contains
nicotine
 No good evidence of efficacy in pregnant smokers
 But experts agree that there is less risk than
continued smoking
-smaller dose of nicotine
- slower delivery
- not absorbed into the respiratory system
- doubles the chances of success in the
general population of smokers
Weighing up the risks
 ‘..risk of cigarette smoking during pregnancy is far
greater than the risk of exposure to nicotine.’
 ‘…use of NRT is probably not without risk…’
 ‘On balance the use of NRT to aid smoking
cessation during pregnancy seem reasonable.’
Benowitz & Dempsey, 2004
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Recommendations
 1. NRT be used in combination with behavioral
support
 2. Use the lowest dose of nicotine effective for
achieving cessation (oral products better)
 3. If cannot tolerate oral products (i.e. due to
nausea) use a patch
 4. If using a patch, use 16-hr only
 5. Initiate treatment as early as possible
Integration for Success
 Nicotine Patch duration – 8 weeks is effective
 Treatment efficacy using one clinician type increases
success by 18.3% (PHS Guidelines, 2000)
 Combination of Behavior Modification Therapy and
pharmacotherapy (NRT) is more effective than either one
alone (Treatment Strategies U. Mass Medical School TTST Manual)
AN “ENHANCEMENT”
OF BEST PRACTICE
 Some smokers need longer course of treatment
 Duration tailored to meet individuals needs.
(US Health & Human
Services 10/2000)
 Combination of pharmacotherapies – Evidence suggests that
combining the patch with either nicotine gum or lozenge
increases long-term abstinence rates over those produced
by a single form of NRT (US Dept Health Human Service PHS Guidelines, 2000)
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Breastfeeding
 Serum concentrations of nicotine in breastfeeding
infants are low
 This is even lower in mothers using NRT compared
to smoking
 ETS is more risky to the infant
Nicotine Replacement Therapy
 Nicotine Patches
 Nicotine Gum
 Nicotine Lozenge
 Nicotine Nasal Spray
 Nicotine Inhaler
 Buproprion (Zyban)
 Varenicline (Chantix)
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Nicotine Replacement Therapy
 When smokers stop smoking, nicotine levels drop by half
every 2 hours
 Develop withdrawal symptoms (anxiety, cravings,
difficulty concentrating, depression, hunger, irritability,
poor sleep, restlessness)
 Several products are available
 Using NRT doubles your chances of quitting
 NRT is safer than smoking because it only has nicotine,
not all the other toxins contained in tobacco
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9/17/2008 10:19:21 AM
Nicotine Vaccine
NicVAX™
Early studies on NicVAX®, the Nicotine Vaccine show
• blocks nicotine's entry into the brain
• induces production of long-lasting antibodies that
helped prevent smoking relapse for up to 2 months
in about a quarter of the study participants
• it to be safe (studies have not confirmed safe use
during pregnancy)
• “this new approach could dramatically enhance
the effectiveness of current treatments for
nicotine addiction
Source: Dr. Nora D. Volkow, NIDA Director
PATTERNS OF QUITTING
AMONG ADULTS
Conclusions from Behavioral
Intervention Studies
 Pregnancy is a good time to intervene
 Brief counseling works better than simple advice
to quit
 Counseling with self-help materials offered by a
trained clinician can improve cessation rates by
30% to 70%
 This brief intervention works best for moderate
(<20 cigarettes/day) smokers
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Percent of Ever Smokers Who have Quit, by
Race/Ethnicity—United States, 1978-2004
Percent
70
60
African
American
50
American
Indian
Asian
40
Hispanic
30
White
20
10
0
19781980
19831985
19871988
19901991
19921993
19941995
19971998
19992000
2001200320022004
Year
Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data
Percent of Ever Smokers Who have Quit,
by Race/Ethnicity—United States, 2003-2004
African
American
70
60
52.9
Percent
50
American
Indian
52.5
45.4
Asian
39.6
40
33.2
Hispanic
30
White
20
10
0
Source: National Health Interview Surveys, 2003-2004, aggregate data
Initiation Rates among White Females by Birth
Cohorts, by Age—United States, 1900-1975
Percent
1900
1910
1920
1930
1940
1950
1960
1970
1975
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
5
10
15
20
25
30
35
Age
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QUITTING AMONG ADOLESCENTS
Quit Attempts in the Past Year, by Gender—
United States, 2004
Males
Females
100
Percent
80
62.33
66.88
60
62.98
51.78
40
20
0
Middle School
High School
Source: 2004 National Youth Tobacco Survey
The 4 D’s
• Deep breathe
• Drink water
• Distract
• Delay
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RELAPSE
 Relapse Prevention
 Avoiding Triggers
 What Are My Main Triggers?
 Adjustments to Your Lifestyle
 HALT: Manage Feelings That Trigger
Cravings
Relapse Prevention
 Millions of Americans quit for awhile but return to
smoking/tobacco use. When this happens it is not necessarily a
failure! Each quit attempt provides valuable information about
the process of quitting
 It’s OK to admit the “relapse” and MOVE FORWARD, returning
to your goal to quit.
 Don’t get down on yourself
 Think through the process and choose to get back on track as
soon as possible before you revert back to your old
smoking/tobacco routine
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9/17/2008 10:19:21 AM
Percentage of Ever Smokers* Who Have Quit,
†
by Education—United States, 1966-2004
70
% Former Smokers
60
50
40
30
<12
12
13-15
16+
20
10
0
1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1997 2000 2003
Year
Source: 1966-2004 National Health Interview Surveys
*Ever Smoked 100 + Cigarettes
†Also known as "quit ratio"; estimates since 1992 incorporate some-day smoking
Managing Stress
 Stress is the leading cause of relapse for smokers
 Each year 83% of quitters return to smoking/tobacco use
because of stress-related problems
 Try different stress management techniques until you find
what works and is comfortable for you
 Here are some examples to consider:
Meditation, Stretching, Deep Breathing,
Massage Therapy, Aromatherapy, Exercise,
A healthy diet, music and laughter!
Lifestyle Review
What changes will you make?
Nutrition/Eating
Exercise/Activity Style
Spiritual/Stress Management
Healthy Living
Lifestyle Support Resources
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Nutrition and Exercise
 Research studies show that the nicotine in cigarettes
is responsible for increasing your metabolic rate
 Due to the higher metabolic rate when smoking, the
ex-smoker now has a lower metabolic rate and burns
100 to 200 fewer daily calories
 Nicotine can serve as an appetite suppressant—many
people rely on that fact to keep their weight down.
HALT
 Feelings of hunger, anger,
loneliness and
fatigue may
serve as triggers to return
to smoking/tobacco use
 Two-thirds (67%) of people
return to
smoking when
they experience any
of the
above feelings for long
periods of time
How Much $$$ Will You Save?
 Each day take the amount of money you spent on
cigarettes and put it away.
 Reward your hard work with something at the
end of the year. You deserve it!
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12 OFFICE
SETUP
Steps To
Implementation
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9/17/2008 10:19:21 AM
CDC Best Practices for Comprehensive Tobacco Control Programs
 Establish smoke-free policies and social norms;
 Promote and assist tobacco users to quit;
 Prevent initiation of tobacco use.
CLINICAL PRACTICE GUIDELINES FOR TREATING TOBACCO USE
AND DEPENDENCE
Tobacco dependence is a chronic condition
Effective treatments exist
Identify, document & treat every tobacco user
Brief treatment is effective
Strong dose-response relationship
Counseling, social support and outside treatment
Nicotine replacement therapy
Treatments are cost-effective
US Public Health Service Guidelines
 Clinic screening systems such as expanding the vital signs
to include tobacco use status, or the use of other reminder
systems such as chart stickers or computer prompts are
essential for the consistent assessment, documentation and
intervention with tobacco use
 All patients should be screened for tobacco use and
assessed for their interest in quitting.
 All physicians and clinicians should strongly advise every
patient who smokes to quit.
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9/17/2008 10:19:21 AM
2000 PHS Clinical Practice Guidelines
 Numerous effective pharmacotherapies for smoking cessation
exist. Except in the presence of contraindications, these should
be used with all patients:
– attempting to quit smoking, including bupropion SR, nicotine
gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and
the nicotine lozenge.
– Over-the-counter nicotine patches are effective relative to
placebo, and their use should be encouraged.
 Tobacco dependence treatments are both clinically effective and
cost-effective relative to other medical and disease prevention
interventions. As such, insurers and purchasers should ensure
that:
– All insurance plans include as a reimbursed benefit the
counseling and pharmacotherapeutic treatments identified as
effective in this guideline; and
– Clinicians are reimbursed for providing tobacco dependence
treatment just as they are reimbursed for treating other chronic
conditions.”
Summary: Reaching Tobacco
Users
Referral
Quitlines
Health
care
Tobacco
user
Referral
Referral
Community
Cessation
Programs
269
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The Steps for Becoming a
Tobacco-Free Facility
1. Acknowledge the profound
challenge tobacco creates for the
treatment community
2. Establish a leadership group or
committee and secure the
commitment of the organization
in writing
3. Develop a tobacco-free policy
4. Establish a policy
implementation timeline with
measurable goals & objectives
5. Conduct staff training
6. Provide ongoing recovery options
for staff who use tobacco
7. Assess and diagnose tobacco use
in patients and use this in treatment
planning
8. Incorporate tobacco & nicotine
information in patient education
curriculum
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9. Establish ongoing communication
with 12-Step recovery groups,
professional colleagues, and referral
sources about policy changes.
10. Require staff to not be
identifiable as tobacco users
11. Establish tobacco-free facility
and grounds
12. Implement comprehensive
nicotine dependence treatment
throughout program
 Ask all patients
– Vital sign
– Medical record
– Electronic database
 Strongly advise all who smoke to quit
 Assess willingness to quit
 Offer brief or intensive counseling
 Prescribe NRT
 Arrange for follow-up
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 Computerized reminders
 Routine cessation advice/brief counseling
 Provider incentives
 Patient incentives
 Quality data
 Trained staff
 Literature in waiting rooms and exam rooms
 Is there a smoke-free policy?
 Who smokes and where?
 Are cessation services available?
 Is there a cessation champion?
 Is tobacco a QI indicator?
 Is NRT accessible?
 How can we help?
dbrown@med.miami.edu
 What services are available?
 How well do they work? CLAS?
 What are the barriers?
 How do you follow up?
 Do you refer to the quit line
 Do you bill?
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CODING
REIMBURSEMENT
 Tobacco use cessation counseling visit
 99406: 3-10 minutes
– $ 13.06 non-facility; $ 12.25 – facility
 99407: >10 minutes
– $ 25.05 non-facility; $ 23.84 - facility
 305.1: Tobacco Use Disorder
 V15.82: History of Tobacco Use
 Must provide other clinically relevant
diagnosis code, such as cough 786.2
 8 visits in 12 months (4 per attempt)
 Can use modifier - 25
 Any eligible provider
 Inpatient or outpatient
 Document time spent counseling
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CONCLUSION
TAKE HOME MESSAGES
 Tobacco is an addiction with significant adverse
health consequences
 Smoking during the reproductive years is
associated with significant risk to the mother, the
fetus, and her children
 Effective behavioral and pharmacologic
interventions are available to achieve tobacco
cessation
 We can implement cessation programs in our daily
clinical practices
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THANK YOU
96