4/13/ % of American women smoke. Most smokers start before 18 years of age. 24% of young women * report smoking within the past month

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1 Welcome to the COPE Webinar Series for Health Professionals! April 17 th webinar: Perinatal Health Behaviors: Women, Weight and Smoking Time: 12 1 PM EST Moderator: Rebecca Shenkman, MPH, RDN, LDN Program Manager, MacDonald Center for Obesity Prevention and Education MacDonald Center for Obesity Prevention and Education (COPE) Goals Provide Continuing Education Partner with agencies and organizations Handouts of the slides are posted at: Participate in Research Enhance Education 04/17/14 Webinar: Perinatal Health Behaviors: Women, Weight and Smoking Presenter: Michele D. Levine, Ph.D. Associate Professor of Psychiatry and Psychology University of Pittsburgh School of Medicine Michele D. Levine, Ph.D. Objectives: Learner will be able to: 1. Identify the relationship between smoking cessation and weight gain. 2. Describe approaches that address smoking cessation related weight concerns. 3. Discuss the postpartum period as it relates to smoking and weight related concerns. Associate Professor of Psychiatry and Psychology Co-Director, WPIC Psychology Internship Program University of Pittsburgh School of Medicine Credits: Notice: This webinar is approved for 1 contact award awarded by ANCC and 1 CPEU awarded by CDR. Suggested CDR Learning Need Code: 4000,4090,4180,5370,6000; Level 2. Neither the webinar planners or the presenter have any conflicts of interest to disclose for this presentation. Villanova University College of Nursing Continuing Education is an accredited provider of nursing education by ANCC. Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). April, ) Weight gain and weight concerns in women smokers 2) Approach to addressing weight concerns among smokers 3) Pregnancy and postpartum smoking 16% of American women smoke Most smokers start before 18 years of age 24% of young women * report smoking within the past month Data from MMWR, 2013 *Middle- and high- school students 1

2 The rate of smoking decline has been slower among women than men Some evidence suggests that women have greater difficulty quitting smoking than men do Concerns about shape and weight are prevalent among women in general For women smokers, these normative concerns may promote or maintain smoking behaviors Differences between men and women smokers that relate to quitting This association between smoking and weight has not been overlooked by the tobacco industry 2

3 On average, individuals gain between 5-10 pounds upon quitting smoking Women are more likely to be concerned about postcessation weight gain than are men Women gain more weight than do men after quitting Weight-concerned women smokers gain between pounds after quitting There is a considerable discrepancy between the amount of weight women expect to gain and the amount they are willing to tolerate Expect to gain 17 lbs Less than 20% would tolerate greater than 5 lbs Levine MD, Perkins KA, Marcus MD. The characteristics of women smokers concerned about postcessation weight gain. Addict Behav. 2001;26: PMID The first women s smoking cessation project was designed to compare two approaches to addressing women s concern about postcessation weight gain We compared a cognitive behavioral program designed to reduce postcessation weight concerns and a behavioral weight control program to prevent postcessation weight gain with a standard cessation program Rationale: Successful prevention of weight gain may help to improve cessation rates among weight concerned smokers Goal of Treatment: Prevent actual weight gain by reducing calorie intake Rationale: Average weight gain during smoking cessation is modest. Modifying women s over-concern about shape and weight during smoking cessation may improve cessation rates Goal of Treatment: Reduce concern about weight gain and promote acceptance of modest weight gain Rationale: Smoking cessation alone requires considerable effort and it may be ineffective to deal with weight gain concerns at the same time Goal of Treatment: Target smoking cessation only without directly addressing weight concerns 3

4 WEIGHT CONCERNS Directed not to count calories Encouraged to snack moderately Emphasized benefits of cessation versus minor disadvantages of modest weight gain WEIGHT CONTROL Provided calorie goal to prevent weight gain Encouraged to control calorie intake Emphasized benefits of cessation and avoidance of undesired weight gain Treatment was delivered in 10 sessions over seven weeks. Women quit smoking one month before the end of treatment. Wt Concern ** Wt Control Standard % Abstinent * * Months postquit Compared to standard: ** p<.001 * p<.05 Wt Concern Weight change (lb) * ** * * Wt Control Standard A cognitive-behavioral treatment designed to reduce women s concern about postcessation weight gain improved long-term smoking cessation outcome This approach also attenuated postcessation weight gain among women who remained abstinent 0 Weight change examined only among abstinent women Months postquit Compared to Standard: ** p<.001 * p<.05 Perkins KA, Marcus MD, Levine MD, et al. Cognitive-behavioral therapy to reduce weight concerns improves smoking cessation outcome in weight-concerned women. J Consult Clin Psychol. 2001;69: PMID

5 Although the weight concerns treatment helped women who are concerned about postcessation weight gain to quit smoking, the overall cessation rates are low Rates of abstinence decline sharply at the conclusion of treatment ** * ** p=.006 * p =.05 Bupropion enhanced cessation rates among women receiving a CBT treatment for weight concerns Cognitive behavioral treatment to ameliorate weight concerns may enhance the efficacy of bupropion Thus, CBT to address weight concerns may be a useful tool to enhance smoking cessation rates among women smokers concerned about weight gain Levine MD, Perkins KA, Kalarchian MA, Cheng Y, Houck PR, Slane JD, Marcus MD. Bupropion and Cognitive Behavioral Therapy for Weight Concerned Women Smokers. Arch Intern Med. 2010; 170: How do you do CBT for weight concerned women smokers? Designed to address normative, yet dysfunctional, concerns about weight gain Goal is to ameliorate concerns about smokingrelated weight gain to increase success at quitting smoking Levine MD, Marcus MD, Perkins KA. Women, weight and smoking: A cognitive behavioral approach to women s concerns about weight gain following smoking cessation. Cogn Behav Pract. 2003;10:

6 Adapted from the cognitive behavioral treatment of eating disorders Treatment Features Psychoeducation about smoking and weight gain Cognitive strategies to target irrational thoughts and beliefs about weight gain and smoking Emphasis on moderation Psychoeducation Information on average weight gain pounds Dieting to prevent weight gain may be detrimental Moderate weight gain related to success Explain assumptions of cognitive-behavioral approach Thoughts-Feelings-Behaviors connected Changing ideas about smoking, eating, shape and weight will be gradual and take effort Identify and modify dysfunctional thoughts and beliefs Dysfunctional beliefs are often particularly harsh versions of societal attitudes Introduce self-monitoring of thoughts and feelings Consistent with self-monitoring of smoking Monitor thoughts about eating and weight Questions on Thoughts Diary Thoughts prior to smoking? Thoughts prior to eating? Where are you and what s happening when smoking? SITUATION Describe the event leading up to thoughts or feelings. (e.g., sitting at table after a meal) AFTER DINNER WITH MY HUSBAND THOUGHT(S) FEELING(S) Response(s) I WANT DESSERT BUT DON T WANT HIM TO SEE MY EAT MORE AFTER A FULL MEAL FAT, FULL, ASHAMED THAT I WANT DESSERT I EXCUSED MYSELF TO GO OUT AND SMOKED Use examples from diaries to highlight common beliefs about smoking and weight. Thought: I don t want to eat this cake, I need a cigarette. Belief: It s better to smoke than to eat fattening foods. 6

7 Discuss benefits and consequences of belief Work toward more moderate thoughts Although I might gain some weight, I m proud of my healthier behavior as a non smoker. Encourage women to challenge expectations about weight gain I m going to blow up like a balloon when I quit. Average weight gain is around 12 pounds. Although I am concerned about it, I am unlikely to gain 80 pounds. Target women s efforts to restrain eating Smoking is the only way to keep from eating desserts. Although smoking used to help me avoid dessert, there are other things I can do. I am not allowed to eat ANY snacks after quitting smoking to avoid weight gain. Moderate snacking may help with urges and is unlikely to result in a large weight gain. Recognize and reevaluate rigid rules about eating I have to diet to prevent weight gain. Dieting is unlikely to help and may hurt my chances of quitting successfully. Goals of Treatment: Reduce concern about weight gain Promote acceptance of modest weight gain Increase likelihood of quitting smoking or prevent resumption of smoking 7

8 Mothers Infant/child/family Screening for future risk Smoking during pregnancy is associated with numerous negative health consequences Low birth weight, premature delivery, spontaneous abortion Decreased infant arousal and lung function SIDS Smoking and weight-related behaviors are relevant to perinatal and long-term health 11% smoke during pregnancy 50% of women quit smoking as a result of pregnancy Pregnancy is the most common time in a woman s life to quit Approximately 65% of women who quit during pregnancy will resume smoking by six months postpartum 25% of women will relapse in the first month postpartum Smoking during the postpartum period has deleterious effects on the health of women and their children Postpartum smoking has been associated with : Respiratory illness, ear infections SIDS Cognitive and behavioral consequences Are there other potentially modifiable factors that relate to postpartum smoking relapse? 8

9 Pregnancy Postpartum Period MOOD CHANGES Postpartum hormonal changes Baby blues Stresses of young motherhood Changes in role and self perception Increased Vulnerability Smoking Relapse Smoking Cessation INCREASE IN WEIGHT CONCERNS Retention of pregnancy weight gain Desire to return to pre-pregnancy weight Change in perception of body shape Levine, MD & Marcus, MD (2004). Archives of Women s Mental Health Pregnant women (N = 183) who had recently quit smoking were recruited from obstetrical clinics Women completed assessments during pregnancy and at 6, 12 and 24 weeks postpartum Mean (SD) Age 24.2 (5.4) Weeks of pregnancy 31.9 (3.6) % African American 38.3 % Income less than $10, % College graduate 19.6 % Pregnancy intentional 34.3 Weeks quit 20.6 (10.4) Years of smoking 9.0 (5.7) Cigarettes/day prior to quitting 14.2 (10.4) Nicotine dependence 3.5 (2.1) 65.3% had resumed smoking by 24 weeks postpartum Relapse occurred 43.8 (± 45.2) days after delivery % High motivation for abstinence 63.9 % Intend to breast feed postpartum

10 Relapsed (n = 83) M (SD) Abstinent (n = 44) M (SD) Age* 23.9 (4.9) 26.1 (5.7) Weeks quit during pregnancy * 18.5 (12.2) 25.1 (13.3) Years of smoking 9.1 ( (5.4) Cigarettes/day prior to quitting 16.4 (8.3) 15.4 (6.5) Fagerstrom nicotine dependence 3.8 (2.2) 3.4 (2.0) * p <.05 Univariate HR [95%CI] Smoking-Specific Weight Concerns Baseline covariates * HR [95%CI] Weight Concerns (0-10) 1.14 [1.04,1.25] 1.21 [1.02,1.24] Weight Self-Efficacy (0-10) 0.91 [0.83,0.99] 0.92 [0.84,1.02] General Weight Concerns Restraint 0.95 [0.86,1.05] - Disinhibition 1.02 [0.94,1.11] - Hunger 0.95 [0.87,1.04] - Mood Perceived Stress 1.01 [0.98,1.04] - CES-D 1.02 [0.99,1.04] - Positive Affect 0.97 [0.95,0.99] 0.98 [0.95,1.00] Negative Affect 1.02 [0.98,1.05] - *Controlling for nicotine dependence, partner s smoking, race, alcohol use and intention to breast feed. Prospective data on relationship of weight concerns and mood to postpartum relapse Feeling confident to manage weight without cigarettes and positive affect decreased risk of relapse while concern about smoking-related weight gain increased risk of relapse An intervention designed to prevent postpartum smoking relapse may need to address women s concerns about weight and mood Levine et al Am J Prev Med 2010;39(4): Components STARTS SUPPORT Face to face meetings (postpartum) 6 6 Telephone sessions 7 7 Support group Y Y Gift vouchers for attendance at face to Y Y face meetings Education about dangers of smoking Y Y Discussion of urges to smoke Y Y Education on mood and weight Y N Cognitive behavioral skills Y N 10

11 Psychoeducation Information on average weight gain Dieting to prevent weight gain may be detrimental to quit; don t know about postpartum relapse On average women retain about 3 lb. after birth with large variation from woman to woman Identify and modify dysfunctional thoughts and beliefs Target women s efforts to restrain eating Smoking is the only way to keep from eating desserts. Although smoking used to help me avoid dessert, there are other things I can do. I am not allowed to eat ANY snacks so that I can get back to a good weight quickly. Moderate snacking may help with urges to smoke, and is unlikely to result in more weight retained. Recognize and reevaluate rigid rules about body shape and weight I have to weigh what I did before getting pregnant (or less). Thinking this way may lead to smoking. I m pleased with myself for being a nonsmoking a mom. I feel miserable every morning trying to find something to wear. I know this thought can make me want a cigarette to drop some weight, so I m looking at other areas of myself. I am happy with my hair, or lipstick or nails or whatever. My baby is healthier because I don t smoke. I think my partner is unhappy with my looks since I had this baby. Thinking that makes me feel sad and down in general and I will want to smoke. My partner is happy that I am not smoking for our baby s health and my cleaner hair, breath, etc. I m happy to be not smoking and even if I don t like my shape, it s important to think about what he thinks as a reason NOT to light up. I ate six donuts this morning, what do I care about my health. I know this is a version of all or nothing thinking I care about myself in my role as a mom Although I feel like I blew it there is no rule that says I can t eat some donuts now and then and what s important now is how I feel and what I do 11

12 Most smokers believe smoking reduces stress However, if it does, stress reduction is short lived (10 minutes) Staying quit has been shown to lead to a reduction in perceived stress There are other ways to manage stress Incorporate alternative strategies when you might have smoked Practice stress management techniques like deep breathing Life stress Notice and plan for major stressors Relaxation strategies Baths, massage, stretching, deep breathing, relaxing music Self-rewards Make it personal Plan for it to happen Follow through and enjoy it For women smokers, concerns about weight gain are common Addressing weight concerns in combination with smoking cessation treatment can decrease longer-term weight retention Pregnant and postpartum women are an important group to target for health behavior change There appear to be modifiable variables that relate to postpartum smoking relapse and postpartum weight 12

13 Marsha D. Marcus, Ph.D. Kenneth A. Perkins, PhD. Yu Cheng, Ph.D. Melissa A. Kalarchian, Ph.D. Rebecca Emery, B.A. Patricia Gonzalez, M.S. Betsy Polley, Ph.D. Meredith Strassburger, M.S.W. Katherine Tuminello, B.S. Jennifer Slane, Ph.D. Jennifer Grace, M.A. Jackie Rosenstern, M.S.I.S. Gina Sweeny, M.S. Meghan S.C. Wisinski, B.A. Research supported by: R01 HD (PI: Levine) R01 DA (PI: Levine K01 DA15396 (PI: Levine) Evaluations and CE Certificates Everyone who has completed the webinar will be ed a link to the evaluation within 2 business days. The will be sent to the address that you used to register for the webinar. Please complete the evaluation soon after you receive the . The evaluation does expire after 3 weeks. Once expired, you cannot obtain a certificate. Once the evaluation is completed, the CE certificate will be ed separately within 2 business days. COPE s May Professional Webinar (it s free!) Presenter: Kelly C. Allison, Ph.D. Assistant Professor of Psychology, Department of Psychiatry Center for Weight and Eating Disorders Perelman School of Medicine at the University of Pennsylvania Title: Night Eating Syndrome: Diagnosis and Treatment Options Date: Wednesday May 28th, 2014 Time: 12:00PM 1:00PM EDT CE Credit: 1.0 contact hour, 1.0 CPEU To register, go to villanova.edu/cope or Questions and Answers! Moderator: Rebecca Shenkman, MPH, RDN, LDN cope@villanova.edu Web site: villanova.edu/cope To receive monthly s on upcoming COPE events, please join COPE s Contacts on the web site. Thank you for your time and interest. 13