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Tobacco, Alcohol and Drug Use in Childbearing Families. Presented by: Dona Dei, RN/MSN [email protected] Smoking and Pregnancy. Substance Abuse During Pregnancy (SAMHSA, 2005). Based on data collected from surveys of U.S. households in 2003 and 2004:

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Tobacco, Alcohol and Drug Use in Childbearing Families

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Tobacco, Alcohol and Drug Use in Childbearing Families

Presented by:

Dona Dei, RN/MSN

[email protected]

Smoking and Pregnancy

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.

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

Smoking Risks in Pregnancy

  • Ectopic pregnancy

  • Intrauterine growth restriction

  • Placenta previa

  • Abruptio placentae

  • PROM

  • Spontaneous abortion

  • Preterm delivery

  • SIDS (up to 4 timesgreateroccurrence in smoking mothers)

Smoking and Pregnancy

  • Black smokers had substantially higher cotinine concentrations at all levels of cigarette smoking than White smokers.

  • Caraballo, JAMA 280:135, 1998

Smoking and Child Health

Cost of Complicated* Births

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.

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

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).

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

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.

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.

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.

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.

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.

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

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

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.

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.

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

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

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

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

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?

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.

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).

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?

Principles of Brief Intervention:Problem Recognition and Goal-Setting

  • 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.

  • Advise the woman to stop (or cut down) using substances.

  • Emphasize that any action taken is the woman’s choice.

  • Give options for treatment.

  • Get agreement from the woman on at least one action to take.

Follow-up During Pregnancy and Postpartum

  • At each visit, the nurse should:

  • Ask the woman about psychosocial

  • issues.

    • Progress in reducing substance use

    • Use of treatment options

    • Health changes

  • Impart good news.

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.

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.

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.

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.


  • 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

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