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

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Smoking cessation pregnancy l.jpg

Smoking Cessation & Pregnancy

Susan A. Albrecht, PhD, RN

Donna D. Caruthers, PhD(c), RN

University of Pittsburgh

School of Nursing

Supported by: National Institute of Nursing Research

# RO1-NR03233

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Presentation Overview

  • Significance of smoking in the obstetrical patient

  • Brief overview of findings for smoking cessation during pregnancy

  • Review of study findings for smoking cessation with pregnant teenagers

  • Implications for future work

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  • 25% of adults smoke regularly

  • 12.3% pregnant adults smoke during pregnancy (Matthews, NVSS, 49:7, 2001)


  • 1/3 of all teens smoke

  • Teens at risk

    Rural adolescents & Inner city females

    Highest rates of smoking in pregnancy (26%)

    (Matthews, NVSS, 49:7, 2001)

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Teen Smoking & Pregnancy


Age (Years)

Allegheny County, 1995

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Teen Health Risks

  • Respiratory system damage

  • Nicotine Addiction

  • Risk for other drug use (Surgeon General, 1994)

  • Impairs physical endurance & performance

  • Decreased overall health with increases in healthcare visits  (Arday,et al., Am J of Health Promotion,1995;10(2): 111-116)

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Health Risks – Teen Pregnancy

  • U.S  Highest teenage pregnancy rate of developed countries. (CDC, 1999)

  • Low birth weight due to poor prenatal nutritional intake

  • Preterm delivery

  • Obstetrical risks double with teen smoking

    (ACOG Educational Bulletin, 1997;240.)

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Obstetrical Health Risks & Smoking

  • Ectopic pregnancy

  • Placenta previa

  • Abruptio placenta

  • Preterm delivery

  • Perinatal mortality

  • Low birth weight – 2 times greater in smokers

  • Intrauterine growth retardation

    (ACOG Educational Bulletin, 1997;240.)

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Fetus and Infant Health Risks

  • Low birth weight

  • Sudden Infant Death Syndrome (SIDS)

  • Respiratory illnesses Pulmonary, Otitis Media, Asthma

  • School problems Lower scores on spelling & reading tests Decreased attention Risk for hyperactive behavior

  • Increased Hospitalizations

    (Pollack, H.A., Am J Public Health, 2001; 91(3) & ACOG Educational Bulletin, 1997;240.)

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Background – Pregnant Adult

Smoking during pregnancy: Is it a temporary act?

At least 1/3 of all women who quit during pregnancy relapse before delivery. (Ershoff, 1995, Am J Prev Med)

Most women will relapse within 12 months of delivery. (Surgeon General, 2001)

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2000 Clinical Practice Guidelines

  • Guidelines state health care providers must screen and address for tobacco consumption with every smoker at every encounter

  • Treatments as brief as three minutes are effective

  • Use Five A’s to guide your efforts

  • Use Five R’s to guide your efforts with patients unwilling to quit

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Background – Pregnant Adult

Treatment types investigated

  • Harm Reduction – Exposure from spouse

  • Support for spontaneous quitters

  • Prenatal cessation programs

  • Relapse prevention programs

    -Prenatal delivery

    -Post delivery - telephone counseling

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RCT- Adult Relapse



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Predictors of Relapse

Adult Pregnant Smokers

  • Dependence/Tobacco use

  • Passive exposure (spouse)

  • Not breast feeding

  • Self-efficacy

  • Education

    Tobacco Control 2000, 9; supplement

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Another Approach

Extending research to include pregnant teen smokers

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Developmental Theory

Jessor’s Theory of

Problem Behavior Development

  • Teens engaging in one type of problem behavior are more inclined to participate in other problem behaviors.

  • Problem behaviors (e g. Smoking) focus on the role of peers.

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Problem Behavior Theory

Personality System

Social Environment


Behavior System

Perceived Environment System

Adapted from Jessor, Donovan, & Costa (1991)

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Treatment Efficacy

  • What are the short and long term differences in smoking behaviors among pregnant adolescents randomly assigned to either:

    Teen FreshStart (TFS),

    Teen FreshStart with Buddy (TFS-B), or

    Usual Care (UC)?

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Effect of Booster Sessions

  • What is the effect of booster sessions on smoking behavior 1 year after study entry?

    Booster sessions were anticipated to increase cessation rates as measured by self-report and saliva cotinine when controlling for cessation treatment (TFS & TFS-B).

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Predictors of Relapse

  • Does a model consisting of baseline characteristics of social environment, personal, and perceived environmental factors predict adolescent smoking at 12 months following study entry(T4).

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Independent Variables

  • Treatment Group Assignment

  • Telephone Booster Sessions

    Dependent Variables

  • Smoking Abstinence (Objective & Subjective)

    1. saliva cotinine & carbon monoxide

    2. self-report of smoking behavior

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Data Collection

  • Baseline – T1

  • Following 8 week intervention – T2

  • 6 weeks postpartum – T3

  • 1 year following baseline – T4

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Inclusion Criteria

14 - 19 years old

12 - 28 weeks pregnant

Smokes one or more cigarettes/day

Read & understood English

Exclusion Criteria

Pregnancy complications

Confined to home for medical reasons

Study Entry Criteria

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On average, pregnant female subjects (n = 142) were:

  • White (49%; 39%)

  • Single (32%)

  • 17 yrs. old (s.d. ± 1.3)

  • Gestation of 19 weeks (s.d. ± 7.2)

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Baseline Tobacco Use

  • Initiated smoking: 12 years (s.d. ± 2.3)

  • Regular smoker: 13 years (s.d. ± 2.1)

  • Cigarettes/day before pregnancy: 15 (s.d. ± 9.3)

  • Current Cigarettes/day: 7 (s.d. ± 4.6)

  • Nicotine Dependence (FTQ): 4 (s.d. ± 1.9)

  • Previous quit attempt: 78%

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Ethnic Differences

p < .001

p < .001

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Teen Fresh Start - Intervention

Topics of group sessions

1-3: smoking patterns & effects on mom & baby

4: quit day

5: first steps of recovery

6: using coping skills

7: shared experience

8: celebrating healthy choices

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Group, Carbon Monoxide, Booster

CO level ppm

n = 34

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Group, Cotinine, Booster

Cotinine level ng/ml

n = 38

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Predictors of Abstinence

Test of Model X2 = 12.9, 3df, p <.005

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Predictors of Abstinence

Test of Model X2 = 11.9, 4df, p <.018

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  • Short-term tobacco abstinence was effective with the TFS-Buddy intervention.

  • Neither the TFS or TFS-Buddy interventions were effective for long-term tobacco abstinence.

  • Tobacco abstinence during teenage pregnancy may be one event in which a teen’s peers and parents are in agreement.

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  • Further research is needed to improve tobacco abstinence for pregnant adolescents and adults.

  • Teens with heavy dependence may benefit from nicotine replacement medications, but research is lacking in this area.

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Review Questions(developed by Supercourse Team)

Why do you think at younger ages women now smoke more then men?

What are the predictors of relapse?