Fetal exposure to tobacco is the most important identifiable risk factor for poor birth outcomes. It is estimated 70% of all smokers report they do want to quit. Pregnancy presents a great opportunity for a woman to quit. Her motivation to quit is usually highest. According to the surgeon general a pregnant woman who decides to quit does not usually have the side effects non pregnant smokers experience.In one study 80 % of respondents reported getting information about risks of smoking from their doctor. Every encounter with a patient gives us a unique opportunity to help them quit.
Now as you know the smoking question is part of every birth certificate worksheet filled out by mothers. Unfortunately, In Wisconsin, in 2006 the birth certificate data showed that 14.9% of women smoked during the pregnancy. The overall U.S. rate is about 10%. Interestingly, in a rather small study, 33% mothers who were questioned about their smoking responded that they did not remember ever being asked or offered any help to quit. About 25 % remembered help being offered. According to a Wisconsin study by WATT, 215 women patients were asked, and advised to quit by the majority of clinicians however, very few respondents were offered help to quit. The stated difficulty according to the clinicians is lack of confidence in their ability to be effective to motivate the patient to change. I have never been addicted to anything other than caffeine so I personally can not relate to such a strong addiction as nicotine. Relapse usually happens within the first year postpartum.
We probably see this population on our unit too often. Usually due to a complication in their pregnancy that could be a result of their smoking. Doesn’t this picture make you want to cringe? Many times these mothers have a partner that smokes. Often times they are uneducated or have minimal education. The other interesting point in the literature is that they are often times known to have a history of psychiatric problems like depression but many times they are not being adequately treated or are noncompliant with treatment. Also, other substance abuse is often involved.
The effects of smoking reach way back to even before they become pregnant. The low birth weight is directly the result of decreased blood flow to the fetus since nicotine in tobacco causes vasoconstriction. The woman’s chance of having a LBW infant is doubled over a non-smoker in some studies. A preterm baby and LBW baby has increased risk of serious health problems during the newborn period and can have lifelong disabilities. Smokers rate of LBW 11.9%, non smokers is 7.2%. Asthma, URI, otitis media, often from second hand smoke, can all plague infants and small children. Recent studies prove the higher risk of heart defects in children of smoking mothers. They have ultrasonically measure the thickness of the carotid artery walls and found they are thickened in children and young adults of smokers. This thickening can lead to cardiovascular health problems later in life. Think about the level of oxygen rich blood trying to pass through narrowed blood vessels to the brain. So, what can we do to help this situation?
Early Intervention is key. The less smoking during the pregnancy the better the outcome in preventing these problems.Ask all patients their smoking history even remember to use it as a vital sign. Should be a question at the beginning of each encounter(at clinic visits, at admission, again sometime during hospitalization, maybe before they go home) if they have a documented history of smoking.Advise –”Quitting is the most important thing you can do to protect yourself and your baby now and in the future. Let’s discuss how we can help you.” You have to sell it. Accentuate the positive to the situation “You know quitting can help you and your baby get more oxygen, it will help the baby’s lungs mature and work well, we want you to be able to bring baby home healthy, you’ll have more energy and can breathe easier, not buying cigarettes will save you money and you can buy things for you and the baby, your hair and clothes will not have a smoky smell and food will taste better, you’d be doing something really good for your baby”ASSESS- Their willingness to attempt to quit.ASSIST Offer referrals, give handouts, point out what they can do to help them quit. (Refer to handout from March of Dimes). Remind them it has been found that pregnancy itself may help them not have the side effects non pregnant women have when they try to quit so it may be easier now than later.ARRANGE a contact date to see how she is doing with following up. Make it one week from date she will quit.Should take no more than 5-10 minutes. More than that is too overwhelming. You know you’ve done your best to change a life for the better, even if she resists try again at another encounter. Build a rapport with her so she is comfortable and relaxed. Demonstrate genuine care and concern. Appropriate touch and eye contact is important.
Referral hand outs of programs in Dane county to help them quit. If history of depression may need medication and counseling. The highest success rate for non pregnant smokers is a combination of counseling and medication. Nicotine patches and other routes are not recommended in pregnancy. The first breath program offers individual, strength based assistance with decreasing tobacco use. In 2007, 582 women were served. The success rate reported was 76% not smoking in the post partum period. ( I don’t have statistics about their success in the pregnancy.) Putting up posters regarding smoking dangers in offices in strategic locations is recommended.
I highly recommend watching this CME offering since it is so geared toward pregnant smokers. The other sites have vast information and studies about smoking and quitting help. This is just a very small portion of the reliable resources out there.
AS you can see Factsheets are available, and an excellent practice guideline by the CDC is a very thorough resource including information about medications.
Smoking in pregnancy
Perinatal Smoking: what can we do about it?<br />Presented by Jennifer Ulmer RN, BSN<br />St. Mary’s Hospital Family Care Suites<br />
According to studies about 14.9% of women who give birth in the Wisconsin smoke!<br />60% who smoke prior to pregnancy continue during their pregnancy<br />Only 18-25% quit once they know they are pregnant<br />About 18% relapse to smoking postpartum<br />
The typical pregnant smoker is young, single, white, poor, and experiencing an unwanted pregnancy<br />
The Impact on Infants and Young children:<br />Higher infertility and miscarriage rates<br />Small for gestational age <br />preterm delivery<br />Congenital heart defects<br />SIDS<br />Lifelong risks of respiratory illnesses and infections<br />Thickened carotid artery walls<br />
Early Intervention: 5 minute assessment The 5 A’sAskAdviseAssessAssistArrange<br />
Resources available to them:<br />Their physician can support them with referrals, counseling, & medication (postpartum for nicotine) .<br />Toll-free (800)-Q U I T N O W<br />First Breath Program<br />handouts<br />
Resources available to us:<br />The American College of Obstetricians and Gynecologists<br />Smoking Cessation for Pregnancy and Beyond- a free CME course for healthcare providers available at Dartmouth Medical School Web site: http://www.iml.dartmouth.edu/education/cme<br />NIH WAPC <br />March of Dimes wwhf.org<br />CDC PNCC <br />American Heart Association First Breath Program<br />
References:<br />Centers for Disease Control and Prevention. (2007) . Smoking and Tobacco Fact Sheet: Women and Smoking February 28, 2007 retrieved November 30, 2008 from http://www.cdc.org<br />CDC Practice Guideline: Treating Tobacco Use and Dependence(2008)<br />Cuno S.P.M. Uterwaal, M.D., PhD, Katz,M.D.(2008). Arteriosclerosis, Thrombosis and Vascular Biology March of Dimes Foundation. White Plains, NY<br />Hannover, W. (2008) Smoking during Pregnancy & Postpartum: Smoking Rates and Intention to Quit Smoking.Journal of Women’s Health p.17:4<br />Martin, Laurie T. (2008) Correlates Smoking before, during and after Pregnancy. American Journal of Health Behavior p. 32;3<br />U. S. Department of Health and Human Services. (2004) The Health Consequences of Smoking: A Report of the Surgeon General, retrieved November 29, 2008 from http://www.cdc.org<br />Wisconsin Interactive Statistics on Health. http://www.dhsf.wiconsin.gov<br />
Contact Information:<br />Jennifer Ulmer, RN, BSN, IBCLC<br /> Family Care Suites <br /> St. Mary’s Hospital<br /> Madison, WI<br /> (608)258-6860<br /> email@example.com<br />
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