Program Training and Consultation Centre. A Woman-Centred Approach to Tobacco Use & Pregnancy.

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1 A Woman-Centred Approach to Tobacco Use & Pregnancy

2 Introductions Who are you? What organization(s) do you work with or for? Describe the women you encounter that use tobacco. What do you want or need to know by the end of the day? 2

3 Learning Objectives Build skills & confidence using brief tobacco interventions Improve understanding of tobacco use among women Recognize the importance of a woman-centred approach Increase awareness of motivational techniques Practice evidence-informed tools & strategies Learn about and share information about community resources for on-going support and client referrals.any others? 3

4 The Role of Public Health Public Health Role is guided by: Ontario Public Health Standards Tobacco Control Guidance Document Evidence to Guide Action What does the evidence recommend? Ongoing situational assessment (priority populations, directory of available services, gap assessment) Increase awareness of cessation services, promote & refer to existing services NO WRONG DOOR to access cessation support services A social-ecological approach 4

5 Tobacco use is the leading cause of preventable disability & death in Ontario Cost of tobacco use in Canada: $1.6 billion in direct health care costs $4.4 billion in lost productivity At least 500,000 hospital days 5

Health Effects of Tobacco Use Cancers: bladder, brain tumour, breast, cervix, esophagus, kidney, larynx, leukemia, liver, lung, lymphoma, nasal sinus, oral cavity, pancreas, stomach, throat, uterus

6 Health Effects of Tobacco Use Cancers: bladder, brain tumour, breast, cervix, esophagus, kidney, larynx, leukemia, liver, lung, lymphoma, nasal sinus, oral cavity, pancreas, stomach, throat, uterus Respiratory Disease: acute respiratory infections, asthma, bronchitis, chronic airway obstruction, chronic respiratory symptoms, COPD, emphysema, lower respiratory illness, reduced lung function Cardiovascular Disease: abdominal aortic aneurysm, atherosclerosis, coronary heart disease, peripheral vascular disease, stroke Pregnancy: infertility & sub-fertility, low birth weight, placenta previa, preterm delivery, stillbirth, sudden infant death syndrome Other: ear problems, middle ear disease, osteoporosis, peptic ulcers, periodontitis, premature death, surgical complications 6

PREGNANCY COMPLICATIONS Subfertility (female & male) Ectopic Pregnancy (outside the uterus) Spontaneous Abortion (miscarriage) Preterm labour Premature rupture of membranes Placental problems (previa

7 PREGNANCY COMPLICATIONS Subfertility (female & male) Ectopic Pregnancy (outside the uterus) Spontaneous Abortion (miscarriage) Preterm labour Premature rupture of membranes Placental problems (previa & abruption) Growth restriction NEONATAL EFFECTS Low birth weight, smaller head & congenital anomalies Increased perinatal mortality Increased admission to the neonatal intensive care unit (NICU) Sudden Infant Death Syndrome (SIDS) Decreased volume of breastmilk & duration of breastfeeding LONG-TERM EFFECTS Childhood respiratory illnesses (asthma, pneumonia, bronchitis) Other childhood medical problems (ear infections) Learning problems (reading, mathematics, general ability) Behavioural problems Attention deficit hyperactivity disorder (ADHD) 7

8 Women &Tobacco Use 18% of women of childbearing age (20-44 years) smoke daily (CTUMS 2006) 9.9% of Canadian women of childbearing age smoked during the most recent pregnancy (CTUMS, 2007) Estimates of tobacco use among pregnant women in Canada and the U.S. Range from 20 30% 3.3% of Canadian women of childbearing age have a spouse who smoked regularly at home during the most recent pregnancy (CTUMS, 2007) 8

12 Most women cut down or quit when they find out that they are pregnant. Relapse during pregnancy is substantial 25% relapse prior to delivery 50% relapse within four months post partum 70 90% relapse within one year post partum (TEACH, 2009) 12

13 WHY DO WOMEN START SMOKING? 13

14 14 Program Training and Consultation Centre

15 Predictors of smoking Age Education Work status Ethnicity Marital status Alcohol consumption Mother s reproductive history Prenatal classes 15

16 WHY IS IT SO HARD TO STAY QUIT? 16

17 A WOMAN-CENTRED APPROACH What does this mean to you? 17

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26 Awareness of our Assumptions Happy Family Support Networks Teachable Moment Fetus-Focus 26

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31 Most women are not pregnant most of the time. Therefore a campaign directed solely at smoking in pregnancy ignores most women most of the time. Bobbie Jacobson Beating the Ladykillers,

32 The Therapeutic Relationship 32

33 Useful Approaches Listen & affirm Support & encourage Ask questions to help women articulate where they are at Elicit &/or amplify change talk Talk about the woman (before, during & after pregnancy) Include partners/support networks Useful Tools 4As Ask, Advise, Assist, Arrange Stages of Change Rulers (motivation, confidence, readiness) Decisional Balance Why Test Tracking tobacco use Quit Plan 33

34 4As Protocol ASK ADVISE ASSIST ARRANGE 34

35 Stages of Behavioural Change 35

36 36 Program Training and Consultation Centre

37 MOTIVATIONAL INTERVIEWING 37

38 Consider the following What is the rapport between them? Who is in charge? What types of questions were asked? How would you describe their interaction? What change do you think she will make? 38

39 Motivational Interviewing is a client-centred, directive method for enhancing intrinsic motivation 39

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41 ASK LISTEN & REFLECT ELICIT 41

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43 Assessing Readiness IMPORTANCE CONFIDENCE

44 Quitting Motivations and Barriers Qualitative Research, Litmus Research,

45 Questions On a scale of Tell me about What do you like about? Do you have any concerns about smoking? How does smoking fit into your day...? What happened last time you tried? How do you see yourself 10 years from now? What role does smoking play in your life? Reflect, review or summarize. Can I share with you? 45

46 Keeping it Simple Ask & Advise Listen & seek to understand Respect perspective Ask permission, then Assist by offering resources & referrals 46

47 Pharmacotherapy Cognitive-behavioural counselling first Start after first trimester Only consider if woman is highly addicted (>10 cigarettes per day) Intermittent dosing of NRT preferred (e.g., gum, lozenge, inhaler) No evidence of additional risk using Bupropion/Zyban No studies completed for varenicline/champix 47

48 Review Prevalence of tobacco use among women Characteristics of women who smoke & predictive factors re: quitting A woman-centred approach 4As Ask, Advise, Assist, Arrange Stages of Change A Motivational Approach Pharmacotherapy 48

49 Coming Up... Second-hand Smoke & Harm Reduction Community Supports Participant kit Case studies

50 About PTCC Resource Centre of the Smoke-Free Ontario Strategy since 1993 Funded by the Ontario Agency for Health Protection and Promotion Partners include:

51 PTCC Services Technical assistance, training & resource development Knowledge development, exchange & programming to increase the use of research & practice-based evidence LEARN Communities of Practice Media relation training & consultation services through the Media Network in the areas of: Tobacco Control Healthy Eating, Active Living

52 PTCC Training Opportunities PTCC offers workshops and webinars in areas such as: Smoking Cessation Media Advocacy in Public Health Protection and Enforcement Policy Development for Tobacco-free Sport & Recreation Orientation to Comprehensive Tobacco Control in Ontario

53 thank you For more information, contact: Program Training & Consultation Centre

54 Select References Program Training and Consultation Centre Abrams, D.B., Niaura, R., Brown, R.A., Emmons, K.M., Goldstein, M.G., & Monti, P.M. (2003). The tobacco dependence treatment handbook: A guide to best practices. New York, NY: The Guilford Press. Al-Sahab, B., Saqib, M., Hauser, G., & Tamim, H. (2010). Prevalence of smoking during pregnancy and associated risk factors among Canadian women: a national survey. BMC Pregnancy and Childbirth, 10(24), Alcohol-Drug Intervention Service. (n.d). Helping women quit: A guide for non-cessation workers. Available at: Arborelius, E., & Brandell Eklund, A. (2002). Smoke-free pregnancy: Motivational interviewing (A guide for midwives). Stockholm, Sweden: The Swedish Cancer Society. Baxter, S., Blank, L., Guillaume, L., Messina, J., Ecerson-Hock, E., & Burrows, J. (2009). Systematic review of how to stop smoking in pregnancy following childbirth. Journal of Advanced Nursing. Available at: Best Start Resource Centre. (2010). Creating a Smoke-Free Environment for Your Children. Available at: British Columbia Reproductive Care Program [BCRCP]. (2006). BCRCP guideline: Tobacco use in the perinatal period. Vancouver, B.C.: British Columbia Reproductive Care Program. CAN-ADAPTT. (2010). Specific populations: Pregnant & breastfeeding women. Available at: Centre for Addiction and Mental Health [CAMH]. (2007). Exposure to psychotropic medications and other substances during pregnancy and lactation: A handbook for health care providers. Toronto, ON: Centre for Addiction and Mental Health. CTC Working Group. (2010). Comprehensive Tobacco Control: Guidance Document. Toronto, ON: Ontario Ministry of Health Promotion. Coleman, T., Chamberlain, C., Cooper, S., & Leonardi-Bee, J. (2010). Efficacy and safety of nicotine replacement therapy for smoking cessation in pregnancy: Systematic review and meta-analysis. Addiction, 106 (1), Einarson, A., & Riordan, S. (2009). Smoking in pregnancy and lactation: a review of risks and cessation strategies. European Journal of Clinical Pharmacology., 65, England, L.J., Kim, S.Y., Tomar, S.L., Ray, C.S., Gupta, P.C. et al. (2010). Non cigarette tobacco use among women and adverse pregnancy outcomes. Acta Obstetricia, 89 (4), Fiore, M.C., Jaen, C.R., Baker, T.B., et. al. (2009). Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. 54

55 Select References Program Training and Consultation Centre Fiore, M.C., Bailey, W.C., Cohen, S.J., Dorfman, S.F., Goldstein, M.G., Gritz, E.R., et. al. (2000). Clinical Practice Guideline: Treating Tobacco Use and Dependence. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Fornisnash, A.B., Pitlick, J.M., Clark, K., & Alstat, V. (2010). The Annals of Pharmacotherapy, 44, Greaves, L., Cormier, R., Devries, K., Bottoroff, J., Johnson, J., Kirkland, S., et.al. (2003). Expecting to quit: A best practices review of smoking cessation interventions for pregnant and postpartum girls and women. Vancouver, B.C.: British Columbia Centre for Excellence for Women s Health. Isselmann Disantas, K., Collins, B.N. & McCoy, A.C.S. (2010). Associations among breastfeeding, smoking relapse, and prenatal factors in a brief postpartum smoking intervention. Acta Obstetricia et Gynecologica, 89, Levitt, C., Shaw, E., Wong, S., & Kaczorowski, J. (2007). Systematic review of the literature on postpartum care: Effectiveness of interventions for smoking relapse prevention, cessation and reduction in postpartum women. BIRTH: Issues in perinatal care, 34(4), Ontario Medical Association [OMA]. (2008). Rethinking stop-smoking medications: Myths and facts. Available at: Osadchy, A., Kazmin, A., & Koren, G. (2009). Nicotine replacement therapy during pregnancy: Recommended or not? Journal of Obstetrics and Gynaecology Canada, 31, Perkins, K.A. (2001). Smoking cessation in women: Special considerations. CNS Drugs, 15 (5), Pregnets. (2003). Smoking cessation for pregnant and post-partum women: A toolkit for health professionals. Available at: Program Training and Consultation Centre [PTCC]. (2010). Women and tobacco info-pack: Gain a better understanding of how smoking affects women s health. Ottawa, ON: Program Training and Consultation Centre. Registered Nurses Association of Ontario [RNAO]. (2003). Integrating smoking cessation into daily nursing practice. Toronto, ON: Registered Nurses Association of Canada. Registered Nurses Association of Ontario [RNAO]. (2003). Breastfeeding best practice guidelines for nurses. Toronto, ON: Registered Nurses Association of Canada. Reitzel, L.R., Vidrine, J.I., Li, Y., Mullen, P.D., Velasquez, M.M., et. al. (2007). The influence of subjective social status on vulnerability to postpartum smoking among young pregnant women. American Journal of Public Health, 97(8), Salmasi, G., Grady, R., Jones, J., & McDonald, S.D. (2010). Environmental tobacco smoke exposure and perinatal outcomes. Acta Obstetricia et Gynecologica, 89, Smoke-Free Ontario Scientific Advisory Group. (2010). Evidence to Action: Comprehensive Tobacco Control in Ontario. Toronto, ON: Ontario Agency for Health Protection and Promotion. 55

56 Select References Program Training and Consultation Centre Selby, P., & Dragonetti, R. (2007). Pragmatic strategies to help pregnant smokers quit. Smoking Cessation Rounds, 1(7), 1-5. Available at: Training Enhancement for Applied Cessation Counselling and Health [TEACH]. (2009). Helping pregnant smokers stop smoking: An interactive casebased course. Toronto, ON: Teach Project. University of Massachusetts Medical School. (2004). Massachusetts tobacco treatment specialist training manual. Worchester, MA: University of Massachusetts Medical School. Velasquez, M.M., Hecht, J., Quinn, V.P. et al. (2000). Application of motivational interviewing to prenatal smoking cessation: Training and implementation issues. Tobacco Control, 9(Suppl III), iii36-iii40. Alcohol-Drug Intervention Service. (n.d). Helping women quit: A guide for non-cessation workers. Available at: 56

Brief Counselling for Tobacco Use Cessation

Brief Counselling for Tobacco Use Cessation Revised Fall 2011 www.ptcc-cfc.on.ca Overview & Agenda Impact of Tobacco Use Cessation & Comprehensive Tobacco Control Nicotine & Nicotine Delivery Systems Prevalence