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Questions and Answers about Smoking Cessation for Pregnant Smokers

Question: Can health care workers or organizations that don't offer clinical services also use the “5 A’s” to help their clients?

Answer: The counseling protocol is not restricted to OB/GYNs or clinicians, and in several of the clinical trials that examined the effectiveness of smoking cessation interventions, the counselor was a health educator or other trained non-clinician. The techniques defined in the Public Health Service Treating Tobacco Use and Dependence clinical practice guideline and the ACOG Educational Bulletin Smoking Cessation During Pregnancy can be applied by any trained provider. Ordering information.

Question: Should health care providers refer pregnant women who smoke to support groups in their area?

Answer: There are two types of smoking cessation groups that are discussed in the literature: support groups (also labeled self-help) and group counseling with a trained facilitator. Support groups are more informal and require the client to be motivated to attend the meetings on her own. Group counseling may be done in a more structured environment, or even in the prenatal care setting itself, and is organized by a health care professional with knowledge of evidence-based tobacco treatment approaches.

According to the Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, self-help does not appear to have a significant impact on reducing rates of smoking among the general population. Facilitated group counseling, on the other hand, did improve people's ability to quit; 14% abstinence rate versus 10.8% abstinence rate for no intervention.

Proactive telephone counseling and individual counseling were also shown to be effective. Please keep in mind that these studies were not conducted with pregnant women.

Question: I have several pregnant clients who refuse to quit smoking, do you have any advice on how I can motivate them to at least try to stop?

Answer: It is not unusual for many pregnant women who smoke to have a hard time making a commitment to try to quit. But you are doing the right thing by providing them with information on the impact of smoking and the benefits of quitting for themselves and their baby. A variety of techniques for increasing motivation to quit smoking are available in the Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence. They are called the "5 R's": relevance, rewards, roadblocks, repetition and risks. More information on how to use this approach is available in the clinical guide. You can order a copy by calling the Agency for Healthcare Research and Quality at 1-800-358-9295. The Smoke-Free Families "Pregnant Smokers Quit Line Protocol", a guide for providing telephone counseling for pregnant women who are currently smoking or who have recently quit smoking in anticipation of pregnancy or upon learning of their pregnancy may be helpful. View protocol. Some of these approaches are applicable to counseling women face-to-face.

Question: Can pregnant women use pharmacotherapies such as the patch or Zyban to help them quit smoking?

Answer: Our position is to be conservative and recommend that other behavioral interventions are attempted first. But we recognize that individual prenatal care providers may prescribe nicotine replacement therapy for their heavily addicted patients when the benefits of quitting are determined to outweigh the risks of the pharmacotherapies. Clinical judgement will have to prevail until we have definitive studies; a recommended source for making those decisions can be found in Dempsey, DA and Benowitz, NL. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Safety, 2001;24(4):277-322.

There is an article that provides recommendations on how to lower the potential harm of the nicotine replacement patch during pregnancy (Slotkin TA. Fetal nicotine or cocaine exposure: which one is worse? Journal of Pharmacology & Experimental Therapeutics 1998; 285:931-45). They include:

1) Introduce nicotine replacement as early as possible in pregnancy and reduce levels of exposure in second and third trimesters.

2) Women who are light smokers or who spend their day in an environment where smoking is restricted may do more damage to the fetus by using a high-dose nicotine patch than by smoking.

3) For smokers with unrestricted access to cigarettes, replacement therapy would have the benefit of removing the additional toxins found in cigarettes.

4) Lower dose NRTs are preferred and should be removed overnight to allow plasma levels to decay from the steady-state.

5) Pregnant women should be warned that the combination of smoking and a nicotine patch could cause more fetal damage than smoking alone or the patch alone.

Also, GlaxoSmithKlein presents prescribing information on their website (http://pregnancyregistry.gsk.com/bupropion.html) about Zyban (category B) and its impact on pregnancy and breastfeeding:

Pregnancy Category B: (safety in human pregnancies has not been determined) "Teratology studies have been performed at doses up to 450 mg/kg in rats (approximately 14 times the MRHD on a mg/m2 basis), and at doses up to 150 mg/kg in rabbits (approximately 10 times the MRHD on a mg/m2 basis). There is no evidence of impaired fertility or harm to the fetus due to bupropion. There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Pregnant smokers should be encouraged to attempt cessation using educational and behavioral interventions before pharmacological approaches are used. Bupropion and its metabolites are secreted in human milk. Because of the potential for serious adverse reactions in nursing infants from ZYBAN, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Question: What types of interventions are effective for post-partum relapse and reducing environmental tobacco smoke in the home after the baby is born?

Answer: Unfortunately, many of the studies that have examined interventions to prevent post-partum relapse have failed to show significant results. An article called "Randomised controlled trial of a postpartum relapse prevention intervention" by Van't Hof and colleagues studies this issue. View Tobacco Control table of contents containing this article. Because of this gap in the literature, The Robert Wood Johnson Foundation is funding several new projects to identify effective interventions to reduce smoking post-partum. The grantee organizations are listed on http://www.rwjf.org/aboutGrantees/npoDetail.jsp?id=SFP#045257.

In the meantime, the Pennsylvania chapter of the American Academy of Pediatrics has produced a video for clinicians that addresses the issue of post-partum relapse and environmental tobacco smoke. Below is a brief description and ordering information.

"The 'Breaking the Chain' video, funded by GlaxoWellcome, demonstrates stage-based intervention and shows how an office can intervene with a smoker from when they first come in to the office to when they leave. The scenarios include a pregnant woman bringing her child in for ear infection, a father who brings his child with asthma, a mother and an asthmatic son, and a teen smoker. The video targets offices of primary care practices and pediatrician offices, with the goal of intervening to reduce environmental tobacco smoke (ETS) exposure and postpartum relapse. The video is also appropriate for medical students, residents and other professionals. Breaking the Chain videos can be purchased for $25. For information or to order the video or to place an order, call Dottie Schell at 610-527-1023."

You can also order a North Carolina brochure on ETS called "Oh Baby! We Want to Keep You Safe From Secondhand Smoke" by calling either the North Carolina Healthy Start Foundation at 919-828--1819 or the North Carolina Health Resource Line at 1-800-367-2229.

Question: Where can I receive training on how to implement the "5 A's" in my prenatal care practice?

The American College of Obstetricians and Gynecologists has just produced a training manual called "A Self-Instructional Manual for Obstetric Providers: Helping Pregnant Smokers Quit." This paper manual is designed for obstetric providers to train them in how to assess pregnant patient's smoking status and provide appropriate cessation treatment. You can order a free copy of the manual by faxing your name and contact information to ACOG (202-484-3917); emailing smoking@acog.org; or filling out and mailing an order form. If you haven't seen the latest PHS Guidelines for clinicians, you can view them at: http://www.surgeongeneral.gov/tobacco/tobaqrg.htm

There is a webcast on the "5 A's", produced by Cicatelli and Associates, that you can download at: http://webcast.mediaondemand.com/cicatelli/20020111/webcast.html (site temporarily down)

Your local chapter of the American Cancer Society (call the national line at 1-800-ACS-2345 for a referral) may conduct smoking cessation trainings for clinicians, their program is called "Make Yours a Fresh Start Family" and there is a description at: http://www.cancer.org/eprise/main/docroot/PED/content/PED_1_5X_Make_Yours_A_FreshStart_Family

The Pennsylvania chapter of the American Academy of Pediatrics has produced a video for clinicians called "Breaking the Chain." Copies can be ordered from Dottie Schell at 610-527-1023. A description of the video can be located at: http://www.aahp.org/atmc/2000minutes.htm

Please check back with our website - we will have several more products coming out in the near future, including a "virtual mini-fellowship" for clinicians who want to treat pregnant smokers in their practice.

Question: I am a researcher who is designing a survey to ask pregnant patients about their tobacco use. Are there any standardized measures that you would recommend?

Answer: You may want to compare your questions to the ones that are listed in the Tobacco Control article by Melvin and Tucker called "Measurement and definition for smoking cessation intervention research: the Smoke-Free Families experience." It is on the Smoke-Free Families website, at http://www.smokefreefamilies.org/resources/tcontrol.html, look under technical reports.

For broader evaluation issues, one resource is the CDC's Office on Smoking and Health publication titled "Introduction to Program Evaluation for Comprehensive Tobacco Control Programs." You can download the document at: http://www.cdc.gov/tobacco/evaluation_manual/contents.htm