Project TEACH Addressing Tobacco Treatment for Pregnant Women Jan Blalock, Ph.D.

Project TEACH Addressing Tobacco Treatment for Pregnant Women Jan Blalock, Ph.D.

Prevalence of Smoking and Cessation During Pregnancy In 2014, 14% in women with Medicaid coverage versus 3.6% of women with private insurance Quit rates of pregnant women 18.4% with Medicaid versus 28.4% with private insurance

Smoking in Pregnancy and Behavioral Health Disorders Among pregnant women who smoke, 45.1% meet criteria for one or more behavioral health disorders Among pregnant women with nicotine dependence disorder, 57.5% meet criteria for one or more behavioral health disorders

Risks of Smoking During Pregnancy Increases risk for Spontaneous abortion Placental complications Pre term delivery responsible for 10% Low birth weight responsible for 30% Fetal and neonatal death Sudden infant death syndrome

Impact of Smoking Cessation Treatment on Birth Outcomes Women who receive psychosocial smoking cessation interventions during pregnancy have significant reductions in risk 18% reduction in pre term birth 18% reduction in low birth weight Increase in mean birth weight of 41 g

Risks of Smoking in Postpartum Period Increases risk for infant and child Hospitalization Respiratory tract and other types of infections in first 12 months of life Ear problems Slower lung growth and lung function problems in infant School absence

Risks of Depression During Pregnancy High levels of depressive symptoms in mother independently increases risk for Preterm birth Low birth weight This risk is comparable to smoking 10 or more cigarettes per day

Clinical Practice Guidelines Because of serious risks of smoking during pregnancy Offer person to person psychosocial intervention that exceeds minimal advice to quit Problem solving and motivational enhancement Abstinence in early pregnancy provides greatest benefits, but quitting at any point is beneficial Offer effective intervention throughout course of pregnancy

Clinical Practice Guidelines (continued) Provide pregnancy specific smoking cessation materials http://women.smokefree.gov/quit smoking.aspx has materials to help women quit http://women.smokefree.gov/forever freebooklet babies.aspx has booklets to help women who have quit smoking in pregnancy remain smoke free

Clinical Practice Guidelines Tobacco Use Medication In 2008, limited data so the Panel did not make a recommendation

Recent Studies on Pharmacological Interventions Recent meta analysis of pharmacological interventions in pregnancy found NRT with behavioral support may increase smoking abstinence in late pregnancy by 40% NRT had neither positive or negative impact on birth outcomes One study found that women assigned to NRT had improved infant developmental outcomes There was a low level of adherence to NRT regimens in women who participated in these studies

Recent Studies on Pharmacological Interventions (continued) Bupropion is listed as a Category C drug in pregnancy (risk cannot be ruled out) One observational study found higher quit rates in bupropion (45%) than controls (14%) Varenicline is listed as a Category C drug in pregnancy No studies have been conducted

Tailored Treatment for Pregnant Smokers with Behavioral Health Disorders? No studies conducted with exception of Cinciripini et al., 2010 Compared depression focused versus health and wellness control 10 sessions, 60 minutes each Smoking cessation component included motivational and behavioral interventions Demographics 54% African American ~ half were unemployed 25 years of age 76% had lifetime history of MDD 67% recurrent episode

Tailored Treatment for Pregnant Smokers with Behavioral Health Disorders? (continued) Study Outcomes Women with highest levels of baseline depression symptoms had higher abstinence and lower depression in depression focused treatment Women with low levels of depression had worse abstinence outcomes

Relationship of Childhood Trauma to Nicotine Dependence High rates of moderate to severe childhood trauma in the sample 76% had at least one type of trauma 32% emotional abuse 21% physical abuse 33% sexual abuse 34% emotional neglect 25% physical neglect Childhood trauma related to higher levels of nicotine dependence Multiple types of trauma increased nicotine dependence severity

Relationship of Childhood Trauma to Abstinence Increasing amounts of trauma associated with reduced likelihood of abstinence at 6 months post treatment Predicted Abstinence Rates, 6 Months Post-Treatment 0.25 0.2 0.15 0.1 0.05 0 0 3 5 Total Number of Moderate to Severe Trauma Categories

Relationship of Childhood Trauma to Depression Outcome Women with increasing amounts of childhood trauma benefitted more from depression focused treatment for depression, while those in the health and wellness condition did not

References 1. Coleman T., et al. Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 12. 2. Chamberlain C., et al. Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews, 2013, Issue 10. 3. Goodwin R. D. et al. Mental disorders and nicotine dependence among pregnant women in the United States. Obstetrics & Gynecology, Vol. 109, No. 4, 875 883, 2007. 4. Fiore, M. C., et al. "Treating Tobacco Use and Dependence: 2008 Update, Clinical Practice Guideline." Mar. 4, 2015. May, 2008. U. S. Department of Health and Human Services. Public Health Service, Rockville, MD. 5. Oncken C. A. et al. What do we know about the role of pharmacotherapy for smoking cessation behavior or during pregnancy? Nicotine & Tobacco Research, Vol. 11, No. 11, 1265 01273, 2009. 6. Cinciripini P. M., et al. Effects of an intensive depression focused intervention for smoking cessation in pregnancy. Journal of Consulting and Clinical Psychology, Vol. 78, No, 1, 44 54, 2010. 7. Blalock J. A., et al., The relationship of childhood trauma to nicotine dependence in pregnancy smokers. Psychology of Addictive Behaviors, Vol. 25, No. 4, 652 663, 2011. 8. Blalock J. A., et al., Relationship of childhood trauma to depression and smoking outcomes in pregnant smokers. Journal of Consulting and Clinical Psychology, Vol 81, No. 5, 821 830, 2013.