smoking in pregnancy dr catherine angell. plan for this session physiology of smoking in pregnancy...
TRANSCRIPT
SMOKING IN PREGNANCY
Dr Catherine Angell
Plan for this sessionPhysiology of smoking in pregnancy
Physiology of smokingRisks to the woman of smoking in pregnancyRisks to the infant and childRisks to mother and infant of passive smoking
Smoking behaviour in pregnancyReasons why women smoke during pregnancyChanging smoking behaviourThe role of the midwife in relation to smoking
Write 3 words to describe how this
image makes you feel...
...keep hold of this for
later
Physiology of smokingNicotine
Tobacco leaves in cigarettes contain nicotineNicotine is an anti-herbivore chemical found in the nightshade family of plantsIt combusts at only 95oC allowing its vapour to be released when the leaves are burnedNicotine is absorbed through skin and membranesIt is then absorbed into the bloodstream
(Katzung et al., 2006)
Physiology of smoking
Nicotine in the bodyNicotine circulates the body to the brain and crosses the blood-brain barrier in 7 secondsIt binds to nicotinic acetylcholine receptorsDopamine, a ‘feel good’ neurotransmitter, is released in greater quantitiesThe body reduces the production of dopamine to try compensate for the raised levelsBUT the body then increases the number of receptorsAs a result the body craves repeated doses of nicotine
(Katsung et al., 2006)
Physiology of smokingWhy do people enjoy smoking?
Dopamine • feelings of pleasure and satisfaction
Adrenaline• increased heart rate, blood pressure, respiration • release of glucose from the liver• raised blood sugar and appetite suppression
Norepinephrine• increased concentration, sharpness and arousal
Seratonin• calming, pain-killing, sedative effect
Nicotine is unique in the change in effect achieved by different doses
Physiology of smoking
Smoking has particular healthimplications for women
Infertility/delayed conceptionEarlier menopauseOsteoporosisCervical cancerBreast cancer (Odiase, 2009)
Heart attack/stroke if using oral contraceptives
PUBLIC HEALTH ISSUE
Smoking during pregnancy
Researching risk of pregnancy smoking is problematic because
Smoking habits related to social group• Poverty• Less educated• General health• Delay in seeking health care• Other risk factors ; diet, alcohol, medication, drugs• Less likely to breastfeed
Women may be reluctant to disclose level of smokingExposure to passive smoking
(Jarvis and Wardle, 1999)
???
Risks to the woman of smoking during pregnancy
Ectopic pregnancyMiscarriagePlacenta praeviaUrinary tract infectionsPlacental abruptionPre-term labourPremature rupture of membranesHaemorrhage Inadequate breast milk production (Castles et al, 1999)
But not for:Pre-eclampsia (Engel et al., 2008)
PIH (Yang et al., 2006)
Gestational diabetes (Wendland et al., 2008)
Risks to the infant
Nicotine transfer to the infant
Nicotine and carbon monoxide move easily across the placenta
Nicotine and carboxyhemoglobin concentration is 10-15% higher in the fetus than in the mother
Nicotine is also carried in breast milk (Briggs and Freeman,
2005)
Smoking during pregnancy
Note down as many physical effects of
smoking for the FETUS as you can
Risks to the infant IUGRLow birth weightPremature birthPoorer outcomes for
pre-eclampsiaNeonatal mortalityCongenital malformations• Cardiovascular • Cleft lip and palate• Genitourinary• Talipes
Sudden infant death syndrome (SIDS)Respiratory problems,
eg. pneumoniaAsthmaEar nose throat problems, eg. glue earUndecended testes
(Edwards and King, 2007; Graham and Smith, 2007; Malik et al., 2008; Pipkin, 2008))
Risks to the childObesityAsthmaRespiratory disease
MeningitisChildhood cancers (linked to paternal smoking at conception)
DiabetesEarlier menarche (start of periods) and menopauseFertility difficultiesDelayed developmentEmotional problemsBehavioural problemsMore likely to be a smoker
(Gilman et al., 2008)(Sterjfelt et al., 1986; Hofhuis et al, 2003)
Smoking in pregnancy
Smoking in pregnancySmoking rates amongst pregnant women in the UK:
23% in 199519% in 200017% in 2005
(Baxter et al., 2009)
But RCM has noted concern about rises in pregnancy smoking rates since 2005
Why women smoke in pregnancyPhysiologically more difficult to break addiction
during pregnancy...
Adaptation to pregnancy alters how nicotine is metabolisedNicotine clearance improves by 60%Rapid clearing results in a rapid decrease in blood nicotine levelsWomen experience sharper withdrawal and increased craving
(Ebert et al., 2008)
Why women smoke in pregnancy
Get into pairs. Describe the history of a woman who you have cared
for who was/is a smoker
What factors in her life do you think may have caused her to smoke?
Write these down
Why women smoke in pregnancyStress
Experience of smoking appears to offer relief from stress• Pregnancy anxiety, unplanned pregnancy• Money, work, housing• Partner, children, family• Guilt because of smoking
Women may believe smoking is better than stress for themselves, their baby and familyBUT smoking does not actually reduce stress...smoking increases stress hormones and having a cigarette generates dopamine which masks these
(Ebert and Fahy, 2007)
Why women smoke in pregnancyCoping with depression and anxietySocial reasons• Habit and lifestyle• Fitting in with partner/social group (Wakefield et al 1998)
Lack of understanding of risks• Risks of smoking distant and abstract (Graham, 1993)
Weight issues• Weight gain• Small baby=easier birth (Stillman et al., 1998)
Support from health professionals does not meet needs
Changing smoking behaviour
GO back to the woman whose history you described earlier
Did she try to give up?What support did she get?Did it appear to be successful for her?
Changing smoking behaviour
More women stop smoking during pregnancy than at other times in life (McBride, 2003)
33% of women stop smoking during pregnancy
(Edwards and Byrom, 2004)
BUT 25% smoke again with a year (Edwards and Byrom, 2004)
Disadvantaged women least likely to cease smoking (McBride, 2003)
If the woman’s partner smokes she is much less likely to give up (McLeod et al 2004)
Changing smoking behaviour2 major reviews
• Cochrane (2004)• NICE (2009)
Concluded there was a lack of good quality evidenceLittle research has identified the views of women who continue to smoke in pregnancyFurther research required
Changing smoking behaviourSystematic review identified 48 trials......
Methods used for smoking cessation included:Information about cessation schemesCounsellingGroup counsellingPeer supportTelephone supportChemical testing and positive feedbackFetal monitoring and feedbackNicotine replacement therapyRewards and incentives (Lumley et al, 2004)
Changing smoking behaviour
Problems that women experience with smoking cessation advice...Smoking viewed as a lifestyle choice not an addictionThe need to smoke is not understoodAssumption that women will want to give up smoking‘Nagging’ and criticisingFeelings of shame and guiltLack of self-efficacy in pregnancy (Ebert et al. 2009)
Changing smoking behaviour
Research has demonstrated that the most effective programmes are:
Social support (Walsh et al, 1997)
Rewards (Donatelle et al., 2000)
Shared planning of smoking cessation care using a woman-focussed approach (Ebert and Fahy, 2000)
Combined interventions (Ebert and Fahy, 2007)
Role of the midwifeMidwives have a public health role
Midwives see women over a prolonged periodPregnancy represents a ‘teachable moment’
(McBride, 2003)
Role of the midwife
Current guidelines for health professionals:
Ask (about smoking at every opportunity)
Advise (all smokers to stop)Assist (the smoker to stop)Arrange (follow up)
(Raw et al., 1998)
Changing smoking behaviour
Role of the midwife
Difficult to translate broad policy into specific support...NHS ‘Smokefree’ based around their own packs, telephone support and online toolsSpecific pregnancy area in website
www.smokefree.nhs.uk
Role of the midwifeGeneral support for women
START Plan
S = Set a quit date. T = Tell family, friends, and co-workers that you plan
to quit. A = Anticipate and plan for the challenges you'll
face while quitting.R = Remove cigarettes and other tobacco products
from your home, car, and work.T = Talk to your doctor about getting help to quit.
(US Surgeon General Office, 2009)
Role of the midwifeGeneral support for women
Talk to a supporter/friend Keep the house smoke free Keep the car smoke free Have the first cigarette later in the day Make the interval between cigarettes
longer Use the money saved for something
specific Call the NHS Helpline for support and
counseling (adapted from Viccars, 2008)
Think about the woman in the first
slide again...
What words would you use to describe
the image now?
Would you feel better equipped to offer
support?
Thank you!
Dr Catherine [email protected]
Useful references
Baxter, S., Blank, L.,Guillme, L., Messina, J., Everson Hock, E., Burrows, J., (2009) Systematic review of how to stop smoking in pregnancy and following childbirth. London, NICE.
Briggs, G., Freeman, R., (2005) Drugs in Pregnancy and Lactation. Oxford, OUP.
Ebert, G., Fahy, K., (2007) Why do women continue to smoke in pregnancy? Women and Birth, 20 (1)
Ebert, L., Riet, P., Fahy, K., (2008) What do midwives need to understand/know about smoking in pregnancy. Women and Birth, 22 (1)
Lumley J, Oliver SS, Chamberlain C, Oakley L (2008) Interventions for promoting smoking cessation during pregnancy. The Cochrane Library. London, Wiley.
NHS (2009) Smoking in pregnancy. Available from www.smokefree.nhs.uk [accessed Jan 2010]