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 2016 by the author
TREATING TOBACCO DEPENDENCE
IN PREGNANCY
Paraskevi Katsaounou
Assistant Professor of Pulmonary Medicine
Athens Medical School, Evaggelismos Hospital
Chair Group 6.3 Tobacco, Smoking Control & Health Education
ERS
Chair Public Health & Smoking Cessation Group Hellenic
Thoracic Society
[email protected]
Conflict of interest disclosure
 I have no real or perceived conflicts of interest that relate to this
presentation.
 I have the following real or perceived conflicts of interest that relate to this
presentation:
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SMOKING AND PREGNANCY EPIDEMIOLOGY
• 15% to 20% of women smoke while pregnant.
• 20-46% of pregnancy smokers quit during pregnancy although 75%
intend to refrain.
• 60% to 80% of women who quit smoking during pregnancy return to
smoking within 1 year postpartum.
• Many of them prefer even not to breastfeed their newborns in order
to continue smoking.
• Smoking in pregnancy has decreased by 60–75% in high-income
countries but is still increasing in low-to middle income countries
being strongly associated with poverty.
SMOKING AND PREGNANCY
Both active maternal
tobacco smoking and
second hand smoke
exposure during the
perinatal period and
lactation are
undoubtedly the most
important preventable
cause for a variety of
unfavorable
pregnancy outcomes.
Perinatal Complications Associated With
Tobacco Use
•
•
•
•
•
•
•
•
•
Abruptio placenta
First trimester spontaneous abortion
Miscarriage
Stillbirth
Preterm premature rupture of membranes
Preterm delivery
Placenta previa
Ectopic pregnancy
Low birth weight, intrauterine growth
retardation (IUGR)
• Congenital malformation
• Genetic-related hereditary diseases
• Perinatal mortality and morbidity
Fetus reaction when mother smokes….
Ultrasound 3D pictures at week 24, 28, 32 and 36.
Usually fetus move both body and mouth only last weeks of pregnancy.
But when pregnants smoke even at week 24, they react from big discomfort.
OFFSPRING EFFECTS
1.
2.
3.
4.
5.
6.
Asthma
Diabetes
Obesity
Hypertension
Childhood cancers
Reduction in male reproduction
ability
7. Nicotine dependence
8. Lower respiratory infections
9. Neurodevelopmental disorders
10. ADHD
11. Early psychiatric disorders in
early adulthood.
12. Antisocial behavior
13. Sudden infant death syndrome
SMOKING CESSATION PROGRAMS IN PREGNANCY
• Are effective
• Should be implemented as part of routine care for every smoker
that is pregnant, plan a pregnancy or has an infant aged under 12
months.
• Shown to reduce the incidence of low birth weight and preterm
birth.
• Local services should have a health professional trained in
smoking cessation who can provide behavioral support and advice
to pregnant women who want to quit.
SMOKING CESSATION PROGRAMS IN PREGNANCY
• Pregnancy could be “a
window of opportunity” for
smoking cessation since
pregnant could be motivated
from their desire for a healthy
pregnancy and delivery.
• The classical 5As approach
could be shorten as “Very
Brief Advice” ( 3A: Ask,
Advice, Act).
SMOKING CESSATION PROGRAMS IN PREGNANCY
• Are mostly based in
behavioral support.
• Health professionals should
also have in consideration that
there are many aspects and
changes in the psychology of
pregnant women.
• Cognitive behavior therapy,
motivational interviewing and
structured self-help and
support represent for pregnant
women their best chance for
quitting.
HEALTH PROFESSIONALS ROLE IN SMOKING
CESSATION (doctors, midwives)
Advice for quitting
smoking and not reducing
Cessation of active and passive maternal tobacco smoking
during pregnancy are some of the most significant interventions
to lower risk factors for adverse birth outcomes
SMOKING CESSATION IN PREGNANCY
Higher levels of perceived stress, depression,
neuroticism, negative paternal support, and perceived
racism were generally associated with higher odds of
being a smoker than a non-smoker.
Maternal stress may therefore inhibit smoking
cessation during pregnancy and promote a relapse after
pregnancy in women who have achieved abstinence.
Smoking cessation could reveal depression and
thus should be done under medical guidance in smokers
with depression symptoms
Maternal active and passive tobacco smoking during pregnancy .
Vivilaki V, Diamanti A, Tzeli M, Patelarou E, Papadakis S, Lykeridou K, Katsaounou P. Tob Induc Dis. 2016
SMOKING CESSATION IN PREGNANCY
INFORM PREGNANTS
• The perceptions of pregnant smokers regarding the health risks of smoking and
the need to refrain from passive smoking have been described as important
factors influencing smoke-free behavior.
• Despite the fact that women are routinely informed of the risks of tobacco use at
least a third will continue to smoke during pregnancy and many will continue to be
exposed to second hand smoke.
• Addiction to nicotine is such that they reason it with explanations of hyperbolic not
proved dangers for them and their fetus.
• They are young and have not experienced yet any health complication due to
smoking
SMOKING CESSATION IN PREGNANCY
INFORM PREGNANTS’ HUSBANDS AND FAMILY
• Pregnant smokers usually have partners who actively smoked
during their pregnancy.
• A partner who continues using tobacco throughout a woman’s
pregnancy is a significant predictor of the current smoking
status of the pregnant woman.
• The health of pregnant women and their foetuses is inherently
threatened by both active and passive smoking of their
partners or families.
SMOKING CESSATION IN PREGNANCY
Whether or not a pregnancy was desired and planned,
is also a factor that seems to affect the willingness of pregnant
smokers to quit. 43% of mothers did not plan their pregnancy
and 34% were smoking just before and/or during pregnancy.
Therefore, women with planned pregnancies were
observed to be half as likely to be smokers just before
pregnancy, and more likely to give up or reduce the volume of
cigarettes as pregnancy progresses.
Unplanned pregnancies had 24% increased odds of low
birth weight and prematurity, compared to planned pregnancies
independent of smoking status
Maternal active and passive tobacco smoking during pregnancy .
Vivilaki V, Diamanti A, Tzeli M, Patelarou E, Papadakis S, Lykeridou K, Katsaounou P. Tob Induc Dis. 2016
SMOKING CESSATION IN PREGNANCY
Community midwives were most likely to provide
smoking cessation advice and counseling by midwives and
healthcare staff can significantly reduce the volume of
smoking during pregnancy and consequently boost an
increase in birth weight.
Thus, specific training of in smoking cessation is
needed in order to make them adequate in helping pregnant
smokers and reduce relapse rates during postnatal period.
Maternal active and passive tobacco smoking during pregnancy .
Vivilaki V, Diamanti A, Tzeli M, Patelarou E, Papadakis S, Lykeridou K, Katsaounou P. Tob Induc Dis. 2016
Pharmacotherapy for smoking
Cessation in Pregnancy
Nicotine replacement therapy
– Recommended first line therapy
• Long acting
– Patch
• Short acting
–
–
–
–
Gum
Inhaler
Nasal spray
Sublingual tablets/lozenges
Bupropion SR
Varenicline
Nortriptyline
Clonidine
NRTs FOR SMOKING CESSATION IN PREGNANTS
• Controversial
• The metabolism of nicotine is increased during pregnancy so
NRTs can become less effective at standard doses.
• Trial to have followed up infants after birth, suggests that the
use of NRT actually promotes healthy developmental outcomes
in infants mainly if quitting happens the first weeks of the second
trimester which are important for embryo development.
• Using NRT is far safer than actually smoking while pregnant, as
blood nicotine levels are lower when using NRTs, delivered
more slowly and without the other harmful substances contained
in tobacco smoke.
NRTs FOR SMOKING CESSATION IN PREGNANTS
• Advise about its potential risks and benefits if they have so far been
unable to quit smoking by any other means or smoke many cigarettes
per day.
• 15day prescription until the target quitting day.
• Give subsequent prescriptions only when have demonstrated on reassessment, that they are still not smoking or have significantly reduce
smoking.
• Instruct to remove them before going to bed.
• Although guidelines recommend the smallest effective dose, these are
usually ineffective and larger doses or even combination therapy may be
required.
NRTs FOR SMOKING CESSATION IN PREGNANTS
• The efficacy of NRTs in pregnancy increases smoking
cessation rates measured in late pregnancy by approximately
40%, but may not have any increase in abstinence rates in late
pregnancy.
•
Are considered to be of benefit for pregnant women who are
highly dependent and have been unable to quit smoking by
other means .
• We support the use of adequate doses to relieve cravings and
withdrawal symptoms and a full course of at least 8 weeks’
treatment.
National and Kapodistrian University of Athens
Masters in Physiology and Smoking Cessation
“Quitting smoking is easy…
… I’ve done it hundreds of
times.”