AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
JANIS BIERMANN: So the surgeon general came out with a report last year of the health consequences of smoking in which he states that smoking harms nearly every organ of the body and generally diminishes the overall health of women that are smokers and certainly women. Despite the increasing knowledge about the adverse risk that harm to our bodies about smoking, increasing numbers of people continue to smoke and alarmingly a number of women continue to smoke. So my job today is to talk a little bit about what we know of the risks of smoking, the outcome to both women and children and some of the resources we have available to help pregnant smokers quit.
So, best estimates came from really the Surgeon General's report in the year 2001 on the number of women smokers. And it's generally a range of 13 to 22 percent of pregnant smokers smoke and about 20 to 25 of all these women quit smoking once they become pregnant which is the good news, but that still leaves an awful big number of women who continue to smoke. And we have current date that that says in 2002, about 11.4 of the women continue to smoke. And a survey on the National Survey of Drug Use and Health, about 17 percent of the women surveyed said they smoked during a pregnancy. But generally the range is 13 to 22 percent.
This is the map based on the year 2002 data that shows the prevalence of smoking by states, and you see the very dark colors is where you have the highest prevalence of smoking. Again, this is the year 2002 data. But it shows Wyoming Kentucky, West Virginia and New Hampshire -- this is a challenge to my geography -- as the highest prevalence of smoking. And Pam, I looked for Missouri, that's the second highest. So I think this might have shifted in the last year or two but it shows you where the heavy smokers are. The least amount of smokers at least reporting that they smoke are in the States of Virginia, Georgia and Connecticut. Connecticut was my home state, so that was good news.
So the good thing about the new Surgeon General's report is that he very specifically states that there is a cause and effect of smoking to several health conditions. And Steve has already outlined them for you. So that there is what we now know to be a causal relationship with smoking with premature rupture of membranes, placenta previa, placental abruption, preterm deliver, low birth rate, reduced fertility and SIDS.
And actually, the only thing I could find in the literature that has a positive impact is that it does help to reduce the risk of preeclampsia. But it's not something that you consider, smoke so we have less of a chance of preeclampsia. So we are not quite there in our messaging.
so for a premature rupture of membranes for a smoker, Steve said is about two to five times more likely to deliver a baby early. The rate of prematurity, about maybe smoking contributes to about 8 percent of babies born prematurely. And we all know one out of eight babies is born prematurely, that's about 480,000 babies a year. So smoking as a contributing factor there to about 38,000 births a year. And the good news is, though, if you stop smoking in pregnancy, you sort of reduce your risk for delivering preterm. So that is the good news. And in fact, if a women stops smoking in the first trimester, her rate of delivering preterm is really almost to that of a non-smoker. So that is pretty good news. Low birth rate, similarly smoking contributes to about 20 percent of low birth weight babies. There's about a 250 gram difference in babies who are born to smokers than non-smokers. And the more the mom smokes, the bigger the difference in the birth weights. But again, if a women stops smoking early in pregnancy, particularly the first trimester, the chance of delivering a baby with a low birth weight is about those of a non-smoker. So the message to women who smoke is to quit as early as possible.
Now, for birth defects. Most studies haven't really demonstrated a cause and effect to smoking and birth defects, and the Surgeon General's report makes that same statement. There are some studies that suggest there could be an increase risk of smoking to oral cleft, slim reduction, urogenital and gastric GI defects, but the Surgeon General's report says there really isn't sufficient evidence to substantiate a cause and effect relationship to oral cleft , the other two there's certainly a possibility.
And SIDS, as Steve mentioned, for women who smoke, there is about a threefold incident of SIDS for women who smoked both during and after pregnancy and about a twofold risk for women who smoke only after delivery. And the risk really increases with the amount of smoking that a women does.
Smokers are 20 to 30 percent more likely to have a baby born stillborn or have a neonatal death, and studies show between 3.4 percent to 8.4 percent of perinatal debts maybe distributed to smoking.
And breastfeeding. Women who smoke produce less breast milk and also they are not as likely to breast feed as much of a duration as non-smokers.
So we have some research that indicates who is most likely to quit, and we've identified women who are more likely to quit if there's higher income and education, women who are married and have children or partners, women who are having a first child who want to have the pregnancy, who enter prenatal care early, who experience nausea during the first trimester, and who intend to breast feed. So based on research, these are the women most likely to quit. And actually, pregnancy is a time when if there's any time in your life that you're more likely to quit, pregnancy is the best time. And quitters are usually smokers who are light smokers, who have a social circle and who have a strong belief that smoking can hurt their developing fetus, the baby.
So the -- We know that even a brief counseling session or intervention can work and be more effective than giving advise on quitting. So the Five A's Approach was adopted by ACOG, and it's general a five to fifteen minutes of counseling by a trained clinician, so this is a provider intervention and it can improve cessation rates by 30 to 70 percent which is really the good news. And the five A's are promoted by many organizations and some of the them in the room. I'm looking around the room, Katherine, you for sure know this, but how many of you know the five A's? The first one is Ask. The next one is advise. The third is assess. The fourth is assist and the fifth is. (Inaudible.)
so you ask the patient about the smoking status, you advise to quit smoking, you assess the willingness to quit. You assist with skill building and self-help material and then you arrange for follow-up care. This has, I said, has proven to be very effective.
Now you also want to leave with behavioral intervention such as the five A's. And that happens to be a very effective tool for women who are light smokers as we've already discussed. But sometimes women don't have any luck with behavioral approaches or they were heavy smokers. And in that case, it may be appropriate to consider pharmacological intervention. The problem is that pharmacological intervention's haven't been tested for efficacy and safety in pregnant women. So in that case the provider has to weigh the consequences that the heavy smoking on the pregnancy to an intervention, if it has not been proven to be safe and effication. But it really is up to the patient and the provider to decide what is the best approach.
now this is a website, first page of a website. I'm not sure if you can read the URL on the bottom there. With my eyesight I'm not sure if I can read it either. But it's a virtual learning experience for providers. It was developed by the University of Dartmouth and it's interactive so it goes through three patient simulation where you can practice the five A's, which is the good thing, you can practice the counseling skills, it has many, many resources on the web site, there are tool kits, there are lectures, there are materials listed and you can get CME credit as well. So ACOG markets his product and it's a nice tool for clinicians to practice the Five A's and learn more about the psycho-social influences if you will of behavior as it relates to smoking cessation. So hopefully you can read the web site. It's HTTP IML.Dartmouth.Edu.
Now, one of the best resources for pregnant women is the National Partnership to Help Pregnant Smokers quit and AMCHP and ACOG and March of Dimes are very proud to be members of the large coalition. I think there's about 61 member organizations. It's led by Dr. Kathy Melville. And it's based on ix evidence basis aims. The health care system, media, policy, community and work sites, state outreach and research evaluation and surveillance. This is the web site. This is a very rich resource for providers and patients on materials available around smoking, smoking cessation obviously and resources for both sides, for providers and women. So we are very pleased to be part of that partnership.
And there are some other resources at well. We've got the quilt lines listed on here. The 1-800-QUITNOW. Is the new national quit line consortium which we started up. That's composed of state departments, national quit lines researchers who really want to improve the availability and the efficacy of quit lines. They have a map available so you can click on the map and know which quit lines are available in your state and resources there. And certainly counseling and brochures are many of the categories for resources available for pregnant women.
And then there's several organizations that provide materials for pregnant women as well. March of Dimes, smoke free families, ACOG and A-1 and the March of Dimes have material both in English and Spanish. So we have them in print and on the web site.
So the Surgeon General in the year 2001 stated that healthcare costs at delivery for smoking, so health problems related to smoking at birth in the year 2001 totals 336 million dollars. But in the year 2004 report it was that smoking cessation initiatives really could help save money 2 to 3 dollars in health care costs by helping pregnant women quit smoking. I think we always have to keep in mind the economic impact as well.
So to me, the call to action is that we have to help pregnant women quit smoking. And we heard earlier this morning from Dr. Lou that obviously the optimum case is we want to prevent people from smoking and we all want to do that, but we can't stop doing what we can do. And when we see pregnant women smoking, I think the responsibility is on us to have the resource available to reach out to those women, to make sure we ask about smoking status and to provide the services to help pregnant women quit. I think that's one of the more important things we can do. Thank you.