Should I breastfeed or keep smoking? Linked decisions by low-income Shelby County women

Should I breastfeed or keep smoking? Linked decisions by low-income Shelby County women Kenneth D. Ward, PhD Professor and Director, Division of Social and Behavioral Sciences School of Public Health The University of Memphis Shelby County Breastfeeding Coalition -- August 8, 2018 The School of Public Health

Disclosures No relevant financial or nonfinancial disclosures.

Learning objectives Recognize how socioeconomic status and race/ethnicity impact breastfeeding and smoking cessation Understand how decisions to breastfeed and quit smoking are related Identify factors that may link these decisions Discuss strategies to address both of these important risk factors among Shelby County women

Effects of not breastfeeding and Breastfeeding For child Infectious morbidity Childhood obesity Type 1 and type 2 diabetes Leukemia Necrotizing enterocolitis SIDS For mother Premenopausal breast cancer Ovarian cancer Retained gestational weight gain Type 2 diabetes Myocardial infarction Metabolic syndrome smoking Smoking Perinatal Ectopic pregnancy Intrauterine growth restriction, Placenta previa, Abruptio placentae, Preterm premature rupture of membranes Decreased maternal thyroid function Preterm delivery, Low birth weight For child Infantile colic Obesity Asthma Otitis media Respiratory infections SIDS For mother Everything under the sun Both failure to breastfeed and maternal smoking increase risk of infant mortality

Commercial Appeal: 5-26-04 by Karen Pulfer Focht: Inmates (Roscoe Allen and Jerry Nelson) help Robert Savage (left) bury babies in Potter's Field, the county s public cemetery. Shelby County has the highest rate of infant mortality in the United States. More than 14,000 bodies, mostly babies, lay beneath the earth about one mile north of Wolfchase Mall. Many are buried with no ceremony or visitors at all.

Shelby County Health Department, Office of Epidemiology and Infectious Diseases, 2016 Annual Report

Shelby County Health Department, Office of Epidemiology and Infectious Diseases, 2016 Annual Report

Why is smoking during BF a problem? 7.2% of pregnant women in the U.S. smoked during 2016 (~ 300,000 women) About half of women who smoke quit during pregnancy, and of these 40% relapse within 6 months after delivery Infants of smoking and breastfeeding mothers have cotinine urine levels 2-10 times higher than in formulafed babies exposed only to second hand smoke Nicotine exposure is associated with neurodevelopmental problems in children, as well as BF-related problems

Who smokes and doesn t breastfeed? Not Breastfeeding Sociodemographic factors: Low SES (education, income) Younger age African American More children Being unmarried Inadequate social support Prepartum depression Smoking Sociodemographic factors: Low SES (education, income) Younger age White or Native American More children Being unmarried Inadequate social support/partner smokes Prepartum depression

How are we doing with smoking? Shelby County has one of the lowest smoking rates for pregnant women at 5.7% compared to the state average of 14.2% (2015) However, with more than 13,000 births each year in Shelby County, this translates into more than 750 newborns each year being put at needless risk

Is prenatal smoking a good thing?

How are BF and smoking linked? Makes sense that they would, given how health behaviors track together! Clinical trials Among pregnant women in the 2 nd and 3rd trimester, those not intending to BF were more likely to be smoking 1 month postpartum (Simmons et al., 2014) Women who were BF at 8 weeks postpartum were more likely to be abstinent from smoking at 26 weeks postpartum (Kendzor et al., 2010)

Monitoring of Maternal Smoking (MOMS) Purpose: Identify risk factors for continued smoking and relapse during pregnancy and post-partum among low-income women in Shelby County

MOMS Project Phase 1 Qualitative Interviews 60 women recruited from WIC clinics and ROH Smokers and ex-smokers; pregnant and post-partum Interviewed regarding smoking hx, knowledge, motivations, quitting experiences, obstacles, and needs. Phase 2 Prospective cohort study large-scale tracking study based on Phase I results 255 women recruited who smoked cigarettes regularly during the month before finding out they were pregnant Interviewed up to 4 times (twice during pregnancy, twice during the first 6 months after delivery) Data collected 2000-2002 Bi-racial sample (103 Black, 145 White, 7 other )

Baseline differences by race Blacks (n=103) Whites (n=145) p Age (years) 24.2 24.8.1310 % w/ h.s. diploma 49.5 66.9.0060 % married 28.2 55.9 <.0001 % Income < 15k 72.6 41.7 <.0001 Cigarettes/day 12.3 23.0 <.0001 Expired CO (ppm) 8.4 15.1 <.0001 % quit smoking at baseline interview 17.5 20.7.5379 Intend to breastfeed 26.2 46.2.0014 KD Ward et al., American Journal of Health Behavior, 2006, 30, 651-662.

Research questions: 1. Are women who intend to breastfeed more likely to quit smoking? 2. Are women who quit smoking more likely at actually breastfeed? 3. Do women who quit smoking breastfeed longer than women who don t quit smoking?

Measurements Smoking Defined quitting during pre-partum and postpartum as self-reporting no smoking for at least the past week, confirmed with an expired CO of < 10 ppm. Breastfeeding Intent to breastfeed: Do you plan to breastfeed (yes vs. no or don t know) Actual breastfeeding Initiation ( Have you breastfed your new baby at all? ) Duration: ( For approximately how many weeks total have/did you breastfeed your new baby? )

Are women who quit smoking more likely to actually breastfeed? 39% of pregnant women intended to breastfeed 38% actually initiated breastfeeding

Are women who intend to breastfeed more likely to quit smoking? Cessation interval % (n) who quit smoking Adjusted Odds ratio 1 Yes intend to BF Pre-partum 35.1% (n=34) Post-partum 15.5% (n=16) No do not intend to BF 18.0% (n=27) 10.7% (n=16) 95% CI P-value 1.99 1.06 3.74.033 1.27 0.57 2.85.556 1 Adjusted for education, race, number of weeks pregnant, and gravida status Conclusion: Women who intend to breastfeed are more likely to quit smoking during pregnancy, but not during post-partum

Are women who quit smoking more likely to actually breastfeed? Cessation interval Quit smoking pre-partum Quit smoking post-partum Initiation of breastfeeding Yes breastfed 38.0% (n=30) 21.3% (n=16) No did not breastfeed 17.6% (n=23) 10.0% (n=13) Adjusted Odds ratio 1 95% CI P-value 2.49 1.21 5.11.013 2.01 0.84 4.80.115 1 Adjusted for education, race, number of weeks pregnant, and gravida status Conclusion: Women who quit smoking during pregnancy were more likely to initiate breastfeeding.

Do women who quit smoking breastfeed for longer? YES On average, women who breastfed did so for 8.5 weeks Women who were quit for at least one week during post-partum breastfed an average of 3.7 weeks longer than women who did not quit during post-partum: Beta=3.74, SE= 1.81, p=.0428 Pre-partum quitting did not predict duration of breastfeeding

Conclusions Decisions to smoke and to breastfeed are linked among low-income women in Shelby County Neither quitting rates, nor breastfeeding rates, are very good and need attention Unclear why this linkage exists, and how to capitalize on it

What to do? American Academy of Pediatrics (2011): Maternal smoking is not an absolute contraindication to breastfeeding but should be strongly discouraged. infants born to smoking parents are better protected by breastfeeding than by formula feeding. Therefore, if public health policies cannot stop addicted mothers from smoking during pregnancy it is fundamental not to miss the chance of encouraging and supporting breastfeeding. (J.G. Dorea, Matern Child Health J, 2007, 11, 287-291).

Possible reasons that smoking and breastfeeding are linked Physiological factors Smoking may reduce breast milk production, or affect infants response to breastfeeding Smokers produce less milk and have shorter lactation periods Infants exposed to smoking may respond adversely to breast milk: Taste changes; total fat is lower in breast milk of smokers Restlessness from nicotine misattributed as lack of milk Nicotine may suppress infant s appetite or desire to BF Motivational factors Health behaviors are highly correlated in general Women perceive that smoking while breastfeeding is harmful to the baby M. Napierala, Environmental Research, 2016, 151, 321-328.

Comment from a low-income pregnant woman in Arizona I think it (smoking) can affect your breastmilk. I mean, look what it does to you, and..it gets not only into your lungs, but it gets into your bloodstream and everything, so why wouldn t it get into your milk and go to the baby? I don t know what it would do to the baby, but I m sure it would (affect your breastmilk) How might smoking affect breast milk?... It might slow down, you know? And it might kill any nutrients or anything that s in it or vitamins, or it might kill some of it, or make it to where it s not as high as, not as potent (Goldade et al.,. Birth, 2008, 35, 230-240)

MOMS participant in Memphis The best thing that helped me was that I quit for two weeks right after the baby was born. What helped is that I didn t have any cigarettes for those two days I was in the hospital. Then I got home, I had the new baby, all this running around, you know. I was breast-feeding, and I was not going to smoke while I was doing that. For some reason, that seemed so much worse to me. Then when he was two weeks old, he got a stomach virus from me because I got a stomach virus and so he got it through the breast milk. So the doctor and I just thought it was strep throat The doctor said why don t we just quit breast-feeding. Let you get over this stuff and let him get over it. When I quit breast-feeding, I got depressed again and started smoking again. Interviewer: You said that you thought breast-feeding made it worse? It was worse to be smoking while you were breast-feeding. Too many bad things going straight to them, which it does when you are pregnant too. I don t know why. Except for that two-day hospital stay, I wasn t smoking, and so it was going out of my system.

Stress as a common pathway In MOMS, greater perceived stress was associated with failure to quit (OR= 1.90, 95% CI= 1.01-3.56, p=.04) New data from ROH patients: Each point increase in perceived stress was associated with a 31% increase in the odds of smoking during pregnancy (OR=1.31, 95% CI=1.03, 1.67). Among women who reported having a partner during their pregnancy (N=99), each point increase in relationship distress was associated with a 12% increase in the odds of smoking (OR=1.12, 95% CI=1.01, 1.25).

Stress as a common pathway National survey: 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS), of more than 13,000 women who recently gave birth. The odds of continued smoking during pregnancy was 12% higher for each stressful life event endorsed (adjusted odds ratio= 1.12, 95% CI= 1.09, 1.15). Stressful life events: Job loss Couldn t pay bills Moved Homeless Illness in family Death of loved one Separation/divorce Arguing w/ partner more than usual Partner or self jailed In physical fight Substance abuse problem Allen, Jung, Lemieux, Alexander, Allen, Ward, al Absi, manuscript under review.

What resources are available to low-income pregnant women in Shelby County? Smoking cessation TN Quitline Baby & Me TennCare Breastfeeding support??? WIC TN Department of Health breastfeeding hotline Free breastfeeding classes offered by Dr. Stiles/S.C. Breastfeeding Coalition Are support services linked?

Acknowledgements MOMS study was funded by The Urban Child Institute Risa Ramsey, RN, PhD, Owen Phillips, MD, MPH, the staff and patients of Ob/Gyn Services at Regional One Health, and Shelby County Health Department WIC program. Co-investigators: April Carswell, PhD Mark Vander Weg, PhD Isabel Scarinci, PhD, MPH Mary Read, RD, MA Laura Girsch, RD Thank you! For information: Ken Ward: kdward@memphis.edu