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You Quit, Two Quit: Perinatal Tobacco Use Cessation. Sarah Verbiest, DrPH, MSW, MPH UNC Center for Maternal & Infant Health 919-843-7865. Agenda. Effects of Smoking on Maternal and Child Health Disparities in Birth Outcomes Best-Practice Intervention: The 5 As

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You Quit, Two Quit:

Perinatal Tobacco Use Cessation

Sarah Verbiest, DrPH, MSW, MPH

UNC Center for Maternal & Infant Health


  • Effects of Smoking on Maternal and Child
  • Health
  • Disparities in Birth Outcomes
  • Best-Practice Intervention: The 5 As
  • Helping Those Who Aren’t Ready: The 5 Rs
  • Postpartum Relapse Prevention
smoking prevalence among women
Smoking Prevalence Among Women
  • Nationally, between 12% and 20% of women report smoking during pregnancy*
  • In NC, the statewide average of women who reported smoking during pregnancy was 10.2% in 2009, although in some counties as many as 30.6% of babies were born to women who reported smoking during pregnancy.+

* Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for 2002. National vital statistics reports; vol 52 no 10. Hyattsville, Maryland: National Center for Health Statistics. 2003, 12.

+ North Carolina State Center for Health Statistics. Risk Factors and Characteristics for 2008 North Carolina Resident Live Births: All Mothers. Accessed December 15, 2009. Available from:>

percentage of live births to women who smoked during pregnancy

2009 NC Birth Certificate Data

(NC Statewide Average = 10.2%)

Percentage of Live Births to Women Who Smoked During Pregnancy


≥ 19%

(18 Counties)

(60 Counties)

10.3% - 18.9%




≤ 10.2%

(22 Counties)


Sources: North Carolina Selected Vital Statistics Vol 1 – 2009. State Center for Health Statistics

Produced By: Erin McClain, MA, MPH You Quit, Two Quit

tobacco use during pregnancy maternal harm
Tobacco Use During Pregnancy: Maternal Harm

Causal association

  • Premature rupture of the membranes
  • Placenta previa
  • Placental abruption

Probable causal association

  • Ectopic pregnancy
  • Spontaneous abortion
  • Preterm delivery
  • The Health Consequences of Smoking: A Report of the Surgeon General, 2004.
tobacco use during pregnancy infant harm
Tobacco Use During Pregnancy: Infant Harm

Causal association

  • Preterm delivery
  • Small for gestational age
  • Low birthweight
  • Stillbirth
  • Sudden Infant Death Syndrome (SIDS)
  • Increased risk for heart defects

Women and Smoking: A Report of the Surgeon General, 2001

tobacco use during infancy and early childhood
Tobacco Use During Infancy and Early Childhood

Causal association

  • Otitis media
  • New and exacerbated cases of asthma
  • Bronchitis and pneumonia
  • Wheezing and lower respiratory illness
  • May put children at higher risk for chronic diseases and cancer when they are adults

Women and Smoking: A Report of the Surgeon General, 2001

the challenge

Over 60% of all child deaths in NC occur prior to the first birthday. (1000+ /yr)

Deaths related to perinatal conditions and birth defects represent the 3rd leading cause of death for children 1-9.

Racial disparity gaps in child deaths vary among age groups. Gaps are the widest among deaths for children under the age of one. As such the disparities in birth outcomes drive NC’s overall inequities in child death.

African American children represent 24% of the population but 48% of the deaths due to perinatal conditions.

The Challenge
preterm lbw and infant mortality
Preterm, LBW, and Infant Mortality

The leading causes of neonatal death are prematurity, low birth weight and birth defects. SIDS is the leading cause of infant death. African American babies dies of SIDS at higher rates than other babies. Smoking increases the risk of SIDS.

healthy north carolina 2020
Healthy North Carolina 2020

Maternal and Infant Health Indicator – Objective #1

Currently, the death rate of African American babies is 2.45 times the death rate of white babies. North Carolina ranks 21st (among 36 reporting states) for this disparity.

This rate was 2.75 in 1998. North Carolina used to rank 26th in the national (among 35 reporting states) for the highest disparity. Since this time NC has seen an overall decrease of about 10.9% in the disparity rate.

NC Goal, by 2020 this rate will be decreased to no more than 1.92 times. This represents NC’s current pace of decline with an additional 10% improvement over pace.

tobacco use
Tobacco Use
  • Every woman deserves to be screened for tobacco use.
  • Hispanic women are the least likely to smoke, however, with acculturation smoking rates increase.
  • Black women may not smoke as much as Native American women and Non-Hispanic White women but they do use tobacco. In counties with high rates of tobacco use we find that Black women smoking.
  • African American women have high rates of hypertension and diabetes which increases their risks for problems when they use tobacco.
  • Lumbee women are more likely to use smokeless tobacco than other groups of women.
the 5 as
The 5 As

ASK the patient about her smoking status

ADVISE her to quit smoking with personalized messages for pregnant and parenting women

ASSESS her willingness to quit in next 30 days

ASSIST with pregnancy- and parent-specific self-help materials & social support

ARRANGE to follow-up during subsequent visits

the 5 as standing the test of time
The 5 As: Standing the Test of Time
  • Since the Public Health Service Guidelines were published in 2000, conclusions have been validated in additional trials
  • For light to moderate smokers, extended or augmented counseling increases the likelihood of cessation
  • Many enhancements have been tested but none have produced results compelling enough to change current recommendations
intervention makes a difference
Intervention Makes a Difference
  • 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%
  • Intervention works best for moderate (<20 cigarettes/day) smokers
  • Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000.
  • Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counseling for pregnant women who smoke: a review of the evidence. Tob Control 2000;9(suppl III):iii80–iii84.
  • Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26:577–589.
quitline nc 1 800 quit now
Quitline NC – 1-800-QUIT-NOW
  • The Quitline provides free, confidential counseling from 8 a.m. to 3 a.m., seven days per week
  • Fax referral forms in English and Spanish can be accessed from the NC Health and Wellness Trust Fund’s Quitline NC website at
patients who decline to quit using the 5 r s
Patients Who Decline to Quit: Using the 5 R’s

RELEVANCE: Help patient figure out the relevant reasons to quit, based on their health, environment, individual situation

RISKS: Encourage patient to identify possible negative outcomes to continuing to use tobacco

REWARDS: Encourage patient to identify possible benefits to quitting

ROADBLOCKS: Work with patient to identify obstacles to quitting and potentially how to overcome them

REPETITION: Address the 5Rs with patients at each visit

postpartum relapse predictors
Postpartum Relapse: Predictors
  • Level of concern about weight gain
  • Intention to quit and self-efficacy
  • Intention to breastfeed
  • Smoking behavior of family and friends
postpartum relapse prevention strategies
Postpartum Relapse:Prevention Strategies
  • Begin relapse prevention counseling and skills building toward the end of pregnancy
  • Focus on benefits of quitting for woman
  • Highlight harms associated with secondhand smoke for infant
  • Involve pediatric providers, including well-child, WIC, early intervention, etc.
additional resources
Additional Resources

If you are interested in learning more…

Unnatural Causes: Are Inequities Making Us Sick?

Race, Stress and Social Support: Addressing the Crisis in Black Infant Mortality by Fleda Mask Jackson

Overview slides about the Infant Mortality & Racism Action Learning Collaborative