IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 1 of 9
Last Published: Sept. 2006
IWK Health Center
Halifax, NS.
Clinical Policy and Objective Manual
Smoking in Pregnancy:
Support and Intervention for Women Admitted to PSCU
______________________________________________________________
A.
POLICY
In recognition that smoking is an addiction and has associated health risks to the mother
and fetus, every woman will be assessed regarding her cigarette smoking status and will
be offered education and counselling appropriate for the stage of contemplation regarding
smoking cessation that applies to them.
B.
PURPOSE
To provide consistent, supportive team efforts to assist the woman, with her consent, to
cease or abstain from cigarette smoking.
C.
GUIDELINES
1. Positive support and reinforcement will be given to women who have quit smoking
as well as those who have decreased the number of cigarettes smoked by all team
members.
2.
All women who disclose that they currently smoke cigarettes will be informed of the
IWK Health Centre smoke free policy (policy # 104.2 Administrative Manual).
3.
For women, who are on bed rest or experiencing other interventions and health
situations that impede their ability to freely go outside to smoke cigarettes:
i. Supportive interventions that facilitate smoking cessation will be explored
with the woman, including the offer of nicotine replacement therapy (NRT) to
prevent nicotine withdrawal symptoms. (See Appendix I and II)
ii. A medical order is required for nicotine replacement therapy for women
admitted to PSCU during their inpatient stay.
4.
Assessing readiness to decrease or cease tobacco cigarette smoking:
i. During the initial nursing admission assessment, all women will be asked if
they smoke cigarettes.
ii. If a non-smoker, ask if she ever smoked cigarettes. If a previous cigarette
smoker, ask when she quit.
iii. If the woman is a current cigarette smoker, the nurse will share a concern
about her smoking status related to woman's health and fetal health risks.
iv. The nurse will ask if she is considering decreasing or quitting her
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 2 of 9
Last Published: Sept. 2006
smoking in the next month. This will determine the stage of readiness she is at
in relation to smoking cessation.
a. Pre-contemplation: if the woman has not considered smoking
cessation, the nurse will inform her that it is her choice to stop smoking.
Current information available on PSCU on smoking cessation will be
offered.
b. Contemplation: If the woman has considered quitting but is not
planning to within the next month, the nurse will reinforce her motivation
to quit, and encourage the woman to focus on the reasons for quitting.
Discuss possible resources to assist in her decision making around
cessation . Current information available on PSCU on smoking cessation
will be offered.
c. Preparation: If the woman has considered smoking cessation within
the next month, the nurse will encourage her to set a goal or timeline for
cessation and reinforce her motivation to quit. Discuss possible resources
to assist in her decision to stop smoking. Current information available on
PSCU on smoking cessation will be offered.
d. Action and maintenance: If the woman has recently quit smoking
during the past six months, a PSCU nurse will support her success, and
assess current challenges to maintaining cessation, including triggers for
relapse and use of nicotine replacement therapy as appropriate. (See
Appendix I and II).
D.
SUPPLEMENTAL REFERENCES
Canadian Council on Smoking and Health (1996). Your guide to a smoke free future.
Cofta-Gunn, L, Wright, K. & Wetter, D. (2004). Evidenced-based treatments for tobacco
dependence. Evidence-Based Preventive Medicine, 1, 7-19.
Donatelle, R., Prows, S. Champeau, D. & Hudson, D. (2000). Randomised controlled
trial using social support and financial incentives for high risk pregnant smokers:
Significant Other Supporter program. Tobacco Control, 9, iii67-iii69.
Gebauer, C. Kwo, C. Hayes, E. & Wewers, M. (1998). A nurse-managed smoking
cessation intervention during pregnancy.
Greaves,L., Cormier, R, Devries, K., Bottorff, J, Johnson, et. al. (2003). Expecting to
quit: A best practices review of smoking cessation interventions for pregnancy and
postpartum girls and women. Vancouver: British Columbia Centre for Excellence for
Women's Health
Go Smoke Free (2006). http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/index_e.html.
Pregnets. (2005) http://www.pregnets.org/providers/about.aspx
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 3 of 9
Last Published: Sept. 2006
Registered Nurses Association of Ontario (2003). Integrating smoking cessation in daily
nursing practice. Nursing Best Practice Guideline. Toronto Canada: Registered Nurses
Association of Ontario
Smokers Helpline. (2006). http://www.cancer.ca.html
E.
AUTHORS/CONSULTANTS/REVIEWERS
Kate Lively, RN MN Manager PSCT
Glenda Carson, RN. MN, Perinatal Clinical Nurse Specialist
Linda O'Neil, RN, Clinical Leader, PSCU
PSCU nursing team
Prenatal Special Care Team
Genetics and Reproductive Health Care Team
Responsibility Of:
Last Review Date:
Cross References:
Target Audience:
Pages:
F.
Women’s and
Newborn Health
Program
Sept. 2006
Smoke Free Policy
#102
Effective Date:
June 2001
Next Review Date:
Policy Number:
Sept. 2009
230
Registered Nurses in
PSCU
9
Policy (ies)
Replaced:
Approved By:
N/A
Genetics and
Reproductive
Care Team
APPENDICES
ASSESSMENT OF NICOTINE DEPENDENCY: Fagerstrom Tolerance Scale
I.
II.
NICOTINE REPLACEMENT THERAPY
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 4 of 9
Last Published: Sept. 2006
Appendix I
ASSESSMENT OF NICOTINE DEPENDENCY
FAGERSTROM TOLERANCE SCALE
1.
How soon after you awake do you smoke your first cigarette?
0. After 30 minutes
1. Within 30 minutes
2.
Do you find it difficult to refrain from smoking in places where it is forbidden, such as the
library, theater, or doctors' office?
0. No
1. Yes
3.
Which of all the cigarettes you smoke in a day is the most satisfying?
0. Any other than the first one in the morning
1. The first one in the morning
4.
How many cigarettes a day do you smoke?
0. 1-15
1. 16-25
2. More than 26
5.
Do you smoke more during the morning than during the rest of the day?
0. No
1. Yes
6.
Do you smoke when you are so ill that you are in bed most of the day?
0. No
1. Yes
7.
Does the brand you smoke have a low, medium, or high nicotine content?
0. Low
1. Medium
2. High
8.
How often do you inhale the smoke from your cigarette?
0. Never
1. Sometimes
2. Always
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 5 of 9
Last Published: Sept. 2006
How to Interpret Nicotine Dependency Score:
Score of 6 or higher: Indicates high nicotine dependency and represents individuals who would
likely benefit from tapering tobacco use and/or the prescription of nicotine replacement therapy
(gum or patch) to decrease nicotine withdrawal symptoms as an adjunct to standard counseling.
Score of 5 or less: Suggests low to moderate nicotine dependency and represents individuals
who may be successful without tapering and/or the prescription of nicotine replacement therapy
(gum or patch). While counseling alone is appropriate, the individual may still wish to use
nicotine replacement therapy to assist with the cessation attempt.
Ask about nicotine withdrawal symptoms experienced with prior quit attempts:
(4 or more indicate nicotine dependency)
▪ Craving Cigarettes
▪ Restlessness
▪ Irritability, Frustration or Anger
▪ Fatigue
▪ Dizziness
▪ Tightness in the Chest
▪ Insomnia
▪ Anxiety
▪ Increased Appetite or Weight Gain
▪ Cough, Dry Throat, Nasal Drip
▪ Constipation, Gas, Stomach Pain
▪ Depressed mood
References:
Heatherton, T. (1991). The Fagerstrom test for nicotine dependence: a revision of the
Fagerstrom tolerance questionnaire, British Journal of Addiction, 86, 1119-1127.
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 6 of 9
Last Published: June 2006
Appendix II
NICOTINE REPLACEMENT THERAPY (NRT)
Smoking cessation medication is intended to used in conjunction with a plan for
supportive counseling, educational materials and long-term community follow-up from
the family doctor or from a health professional who knows tobacco addiction treatment.
Abstinence is challenging to attain and relapse is common. For some people, it may take
10-20 years from the first attempt to stop to become a long-term ex-smoker.
•
•
•
•
•
The key to proper use of stop-smoking medications is to adjust the dosage to prevent
the symptoms of withdrawal and to avoid nicotine toxicity.
In studies to date, the nicotine patch has not been shown to pose a risk in pregnancy,
although some literature expresses caution in using NRT before eight weeks
gestation.
Nicotine in NRT does not cause cancer, heart disease or chronic respiratory disease
and can be considered "clean nicotine".
Nicotine delivered by NRT does not have the same addictive potential as that found
in cigarettes.
When a smoker inhales nicotine into the lungs, it takes only seconds to reach the
brain. This is faster than if it were injected intravenously. Nicotine levels reach a
peak very quickly and then decline rapidly, leading to a need to replace the drug.
The rise and fall of nicotine levels delivered to the brain drive the addiction.
Peak venous blood levels of nicotine are reached in five to ten minutes and has a halflife of approximately 120 minutes. To maintain a blood level of nicotine, smokers
usually smoke a cigarette every one to two hours.
Nicotine delivery method
Cigarette
Spit tobacco
Time to peak blood level
5 – 10 minutes
30 minutes
Nicotine gum
30 minutes
Nicotine patch
2 - 5 hours
•
Route of delivery to brain
lungs to arterial system
oral mucosa to venous
system
oral mucosa to venous
system
epidermis to venous system
If symptoms of nicotine withdrawal or nicotine toxicity appear, the therapeutic dose
and delivery system of nicotine should be adjusted.
While drug use and dosage should be minimal in pregnancy, the amount of nicotine
delivered from medication should be sufficient and prompt enough to avoid
symptoms of nicotine withdrawal (anxiety, inability to concentrate, strong cravings
for tobacco, and a reduced pulse rate). If these symptoms appear then more nicotine
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 7 of 9
Last Published: June 2006
is needed. Heavily-addicted smokers may require the addition of the nicotine gum to
the patch to get enough nicotine to match the levels they usually get from smoking.
Too much nicotine results in nicotine toxicity (nausea, excess salivation, cold
sweat, paleness, and an increased pulse rate). With these symptoms, People who
the person should stop using the NRT until assessed by a physician
A.
Types of Nicotine replacement therapy often used in pregnancy:
a. Nicotine patch:
• Nicotine from the patch is absorbed through the skin, supplying a steady, low level of
nicotine.
• The patch comes in different strengths, usually 21, 14, and 7 mg.
Brands of patches vary in time to peak blood level and in the nicotine levels they
achieve, even when they are rated at the same strength.
The choice of patch strength should be tailored to the individual's level of nicotine
addiction. For example, a person who smokes a pack of cigarettes per day should
begin with the 21 mg patch, and switch to the 14mg patch after 3-6 weeks.
For heavily-addicted tobacco users, it is appropriate to use more than one patch at
a time.
Experienced clinicians tend to prescribe it for a longer, rather than a shorter,
duration.
How to use the nicotine patch
The patch is worn for 18-24 hours and then removed.
A new patch should be applied to the skin.
− The patch should be placed on a different area of skin each day (skin that
is hairless, clean, dry, and not irritated).
− The sticky side of the patch is applied and firmly pressed down for 20
seconds. Hands should be washed immediately after applying the patch to
remove any traces of nicotine.
The patch can be worn while swimming, bathing or exercising.
The patch should be replaced with a new one if it falls off.
Remove the patch two hours prior to strenuous exercise.
When disposing of used patches, it is important to keep them out of the reach of
children and pets as there is enough nicotine remaining in these patches to cause
serious harm.
• If a severe skin reaction occurs, the patch should be removed and the doctor
contacted; 1% hydrocortisone cream may help reduce the rash. Reaction to a patch
may vary between brands.
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 8 of 9
Last Published: June 2006
b. Nicotine gum:
• Nicotine from the gum is absorbed through the cheek and will only be absorbed
through the mucous membranes of the mouth and pharynx.
• If nicotine in saliva is swallowed, it is metabolized in the liver and therefore is not
toxic.
Swallowing nicotine gum may give the person nausea and hiccups.
• Juices, soft drinks, or coffee should not be taken just before using nicotine gum as
mildly acidic beverages tend to reduce nicotine absorption.
If such beverages have been used, rinsing the mouth with water before using
the gum usually manages this problem.
• Nicotine gum is not recommended for patients with jaw issues or dentures.
•
How to use nicotine gum:
Bite the gum slowly.
− After 15 seconds a peppery taste and slight tingling will
appear, indicating that nicotine has been released.
Place the gum against the cheek.
− The peppery taste will begin to fade within minutes.
Bite the gum again
− The peppery taste and tingling will re-appear.
Re-place the gum against the cheek.
− Continue the process until the tingle fades (20-30 min.)
Repeat with next piece as scheduled. Each new piece should be placed against
the cheek in a different area of the mouth from the piece before.
• The gum is available in two strengths - 2 and 4 mg.
The latter is more appropriate for heavily addicted smokers, those who smoke
more than 20 cigarettes /day.
The dose should be from a few to 24 pieces a day, and adjusted according to the
persistence and urgency of withdrawal symptoms or the appearance of symptoms
of nicotine toxicity.
•
The gum works best when used on a set schedule, not just when there is an urge to
smoke (ie. hourly depending on how frequently cigarettes were smoked).
•
After 8-12 weeks of use, one piece fewer of the gum should be introduced every
few.
IWK Health Centre
Woman’s and Newborn Health Program
Clinical Policy and Objective Manual
Smoking in Pregnancy
Page 9 of 9
Last Published: June 2006
Contraindications and adverse effects with stop-smoking medications:
Bupropion (Zyban): there is no current evidence that indicates this drug is dangerous for the
fetus, but the information using the drug in pregnancy is limited. The drug should not be used in
the following situations:
•
•
•
•
•
•
•
Patients taking Wellbutrin®
Patients with a history of seizures.
Patients with a history of bulimia or anorexia nervosa
Patients who are discontinuing alcohol or sedative use
Patients who have taken a monoamine oxidase inhibitor within the past 14 days
Patients taking thioridazine
Patients who have had an allergic reaction to bupropion
Tapering the dosage is not required when terminating bupropion treatment.
•
Nicotine replacement users should be warned to stop using the patch, or gum if any of
the following occur: sudden irregularity in heart beat, severe or worsening angina
(chest pain), severe high blood pressure, a sudden onset of stroke, allergic skin
reactions, increase in ulcer symptoms, or any other worrisome symptom.
References:
Cofta-Gunn, L, Wright, K. & Wetter, D. (2004). Evidenced-based treatments for tobacco
dependence. Evidence-Based Preventive Medicine, 1, 7-19.
Go Smoke Free (2006). http://www.hc-sc.gc.ca/hl-vs/tobac-tabac/index_e.html.
Koren, G. (2004). The Complete Guide To Everyday Risks In Pregnancy And Breastfeeding:
Answers To Your Questions About Medications, Morning Sickness, Herbs, Diseases, Chemical
Exposures And More(Motherisk). Toronto:Robert Rose Inc.
Pregnets. (2005) http://www.pregnets.org/providers/about.aspx
Smokers Helpline. (2006). http://www.cancer.ca.html
Stop-Smoking Medications. http://www.bccancer.bc.ca