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 • 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
Significance Adults • 25% of adults smoke regularly • 12.3% pregnant adults smoke during pregnancy (Matthews, NVSS, 49:7, 2001) Teens • 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)
Teen Smoking & Pregnancy % Age (Years) Allegheny County, 1995
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)
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.)
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.)
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.)
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)
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
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
RCT- Adult Relapse % Delivery
Predictors of Relapse Adult Pregnant Smokers • Dependence/Tobacco use • Passive exposure (spouse) • Not breast feeding • Self-efficacy • Education Tobacco Control 2000, 9; supplement
Another Approach Extending research to include pregnant teen smokers
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.
Problem Behavior Theory Personality System Social Environment System Behavior System Perceived Environment System Adapted from Jessor, Donovan, & Costa (1991)
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)?
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).
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).
Variables 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
Data Collection • Baseline – T1 • Following 8 week intervention – T2 • 6 weeks postpartum – T3 • 1 year following baseline – T4
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
Sample 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)
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%
Ethnic Differences p < .001 p < .001
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
Following Intervention p< .008
Group, Carbon Monoxide, Booster CO level ppm n = 34
Group, Cotinine, Booster Cotinine level ng/ml n = 38
Predictors of Abstinence Test of Model X2 = 12.9, 3df, p <.005
Predictors of Abstinence Test of Model X2 = 11.9, 4df, p <.018
Conclusions • 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.
Implications • 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.
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?