Tobacco Cessation Interventions During Pregnancy

There is no doubt that tobacco use during pregnancy is strongly associated with a variety of avoidable adverse perinatal outcomes like placental abruption, placenta previa, spontaneous rupture of membranes, low birth weight, intrauterine growth restriction, preterm birth, and sudden infant death syndrome.1-5

Alarmingly, newer research indicates that nicotine causes an alteration of production and function of neurotransmitters that may increase the risk of attention disorders, learning and behavior problems, depression, and future nicotine addiction in offspring of pregnant women who smoke.6 The fact that women who smoke in pregnancy experience perinatal mortality rates twice that of non-smokers makes tobacco use in pregnancy the most preventable cause of poor perinatal outcomes.7

Successful treatment of tobacco use can dramatically improve pregnancy outcomes, achieving, for example, a 20% reduction in the number of low birth weight babies and a 17% decrease in preterm births.2 Pregnant women who quit smoking as late as the 30th week of gestation can still positively affect their babies’ birth weight.8,9 It has been estimated that if 1% of pregnant smokers were to quit there would be 1,200 fewer low birth weight infants born each year with a $21 million dollar savings in health care costs. 2

Healthcare professionals, however, often don’t believe this is a substantial problem because they are only aware of a very small number of women who smoke during pregnancy. It is true that prevalence of pregnancy tobacco use in the United States has dropped from 20% in the 1980s to 12% by 2005.6,10,11 The decline, however, has not been consistent among all populations with Alaskan natives, American Indians, and white women having the highest rates.6 In addition, because of the social stigma related to smoking during pregnancy as many as 22 – 50% of women will not disclose that they are smoking.12

Motivation to Quit

Pregnancy is often touted as holding the greatest potential for influencing tobacco cessation. In fact, as many as 45% of women smokers quit before their first prenatal visit.5 Spontaneous quitters tend to quit mostly for the baby’s benefit and are helped by hormonal changes that can cause tobacco to have a bad taste and smell. Typically these women have a history of smoking fewer cigarettes each day for fewer years and have a supportive, non-smoking partner.13, 14

SEE ALSO: Warning Signs of Problem Pregnancy

Women who continue to smoke during pregnancy present the greatest challenge for tobacco cessation interventions. Demographically they differ dramatically from those women who spontaneously quit, are less educated, have a lower socioeconomic level, and minimal social support.5, 14 These women tend to have more emotional problems and often feel that smoking helps them cope with the additional pressures of pregnancy and motherhood.14 Meeting the challenge to assist these women with tobacco cessation holds potential for dramatically improving their pregnancy outcomes.

The devastating consequences of tobacco use calls attention to the critical need for all healthcare professionals to consistently implement tobacco cessation interventions when working with pregnant women. “Treating Tobacco Use and Dependence: 2008 Update Clinical Guideline,” published by the US Public Health Service, outlines the “5 A’s” model, a 5-step evidence-based strategy to assist health care professionals in this endeavor.15

Five A’s

Asking the woman, in a non-judgmental manner, about her smoking status with every contact throughout her pregnancy is the first 5 A’s step. A structured multiple-choice question format should be used. The multiple choice format has been found to improve disclosure rates by as much as 40% in women from a variety of racial and socioeconomic backgrounds.16 A woman, who stopped smoking before attempting pregnancy or stopped smoking with a positive pregnancy test should have her decisions reinforced by congratulating her and reminding her how she is helping her baby and herself. Remember that 25% to 35% of women will relapse during their pregnancy and many women do not initially disclose their smoking status.2,12,15 If she is still smoking, move on to the second step: Advise.
Advisement consists of delivering a strong, clear, concise, personal message to quit smoking in a non-judgmental manner.17 It is never too late to advise patients to quit. Personalized advice should include explicit, positive messages about the benefits for the woman and her baby. Avoid reprimanding the woman and instead begin the discussion about quitting with a statement like, “My best advice for you and your baby is for you to quit smoking; I need you to know that quitting smoking is the most important thing you can do to protect your baby and your own health.” During the discussion focus on the positive aspects of quitting, appeal to her desire to be a good mother, and acknowledge the difficult task of quitting. Reinforce past attempts to quit by reminding the woman that it is common for smokers to make several quit attempts before they succeed.

The third step of the 5 A’s approach is to Assess the patient’s willingness to quit within the next 15-30 days. This can be accomplished by asking key questions like “Are you considering quitting? Are you ready to quit in the next 15-30 days?” Once the woman is ready to quit it is time to move onto the Assist step.

The fourth step in the 5 A’s model, Assist, helps the woman to create a quit plan. Suggest and encourage her to use problem-solving methods and skills for smoking cessation that take into consideration roadblocks that she believes might affect her quit attempt. Encourage the woman to identify and solicit help from her family, friends, coworkers and others who are most likely to be supportive of her quit attempt. Supply pregnancy-specific self-help smoking materials that reinforce counseling and provide additional self-help tips.

The final step of the 5 A’s model is to Arrange for follow-up visits that include repeated assessments of the woman’s smoking status. During these visits the woman’s progress is monitored and the steps she is taking to quit are reinforced as she is encouraged to succeed in her quit attempt.

Overcoming Reluctance

If the woman is not ready to make a quit attempt the tobacco cessation clinical guidelines recommend the use of the “5 R’s” approach to help motivate her toward cessation.15 When a woman declines to make a quit attempt she may find it difficult to voice her reasons or she may think smoking risks do not apply to her. The 5 R’s are useful for identifying issues pertinent to the woman who is reluctant to quit.

Using a 5 R’s approach, the health professional encourages the woman to identify those motivational factors for cessation that are personally relevant to her situation, recognize the risks associated with her continued smoking, describe rewards of quitting for herself and her family, and recognize roadblocks to quitting. Repetition occurs at each encounter as the healthcare professional determines if the woman has changed her mind about undertaking a quit attempt. Motivational interventions are most likely to be successful when the healthcare professional is empathetic, promotes patient autonomy by explaining options, avoids arguments, and supports the woman’s belief that she can accomplish a quit attempt.18

Through the consistent use of the 5 A’s and 5 R’s evidence-based approaches, healthcare professionals can significantly contribute to the health and well-being of mothers and babies by aiding pregnant women to successfully quit smoking.

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11.United States Department of Health and Human Services (USDHHS). Reproductive effects. The Health Consequences of Smoking: A Report of the Surgeon General 2004; 527-602 Atlanta, GA: USDHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
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L. Kim Baraona is course faculty at Frontier Nursing University.

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