WHAT ARE THE FACTS? The use of JUUL s and other electronic cigarettes and their impact on preconception health in NC

WHAT ARE THE FACTS? The use of JUUL s and other electronic cigarettes and their impact on preconception health in NC October 17 th, 2018

Disclosures None of today s presenters have any actual, potential or perceived conflicts of interest related to the contents of this webinar

Acknowledgements This training was developed by the March of Dimes North Carolina Preconception Health Campaign, under a contract and in collaboration with the North Carolina Division of Public Health, Women s Health Branch. Many thanks to Megan Canady, Center for Maternal and Infant Health at UNC-CH, and Jim Martin, NC Tobacco Prevention and Control Branch Thanks to Wake AHEC for their support in providing continuing education credit for this webinar

Housekeeping Obtaining credits Groups viewing together should email: randerson@marchofdimes.org Asking questions Accessing resources at a later date Credits and evaluation

CREDITS Nursing: 1.5 Contact Hours Wake AHEC, Nursing Education, is an approved provider of Continuing nursing education by the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Wake AHEC CEU: Wake AHEC will provide 0.2 CEU to participants upon completion of this activity. National Association of Social Workers (NASW) NC AHEC is a 2018 NASW-NC approved provider of distance continuing education. This program has been approved for 1.5 contact hours A participant must attend 100% of the webinar to receive credit. Partial session credit will not be awarded. Contact Hours: Wake AHEC will provide up to 1.5 Contact Hours to participants. Wake AHEC is part of the North Carolina AHEC Program.

Objectives Learn about various tobacco products, with a focus on new electronic cigarettes, such as JUUL, and other emerging electronic nicotine delivery devices. Understand the health impact of e-cigarettes and secondhand aerosol on youth and pregnant women and describe successful tobacco use prevention initiatives. Increase knowledge of the health risks of tobacco and nicotine use in the preconception period and learn the importance of cessation efforts prior to pregnancy. Participants will learn about ENDS use among reproductive age women in North Carolina and the 5As and 5Rs for screening and counseling. Participants will learn about FDA-approved pharmacotherapy for adults, and their use by pregnant and lactating women.

What Are the Facts? The Use of JUUL s and Other Electronic Cigarettes and Their Impact on Preconception Health in North Carolina March of Dimes North Carolina Jim D. Martin, MS, Director of Policy and Programs N.C. Tobacco Prevention and Control Division of Public Health October 17, 2018

The Burden of Tobacco Use in North Carolina 1 in 5 Deaths in NC due to tobacco use Smoking costs North Carolina $3.81 billion per year in health care costs Including $931 million in Medicaid costs For every death, 30 sick or disabled There is an additional annual cost of $293 million from health problems due to secondhand smoke

90% of tobacco users start before the age of 18

Youth Cigarette smoking is decreasing and was largely unchanged from 2015-2017 PERCENTAGE OF STUDENTS 35 31.6 Cigarette Use in Past 30 Days, NC YTS 30 27.8 27.3 25 20 15 10 5 15.0 11.3 9.3 20.3 5.8 19.0 16.7 15.5 4.5 4.3 4.2 13.5 9.3 8.9 2.5 2.3 2.5 High School Middle School 0 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2017 NORTH CAROLINA YOUTH TOBACCO SURVEY RESULTS

Changing Landscape of Tobacco Products

Overall youth tobacco use was relatively steady from 2015-2017 PERCENTAGE OF STUDENTS 45 Use of Any Tobacco Product in Past 30 Days, NC YTS 40 35 30 38.3 35.8 33.7 28.5 26.6 25.8 25.8 29.7 27.6 28.8 High School 25 20 15 10 18.4 17.4 14.3 10.5 9.1 10.5 9.9 8.6 11.6 10.7 Middle School 5 0 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2017 NORTH CAROLINA YOUTH TOBACCO SURVEY RESULTS 2017 North Carolina Youth Tobacco Survey Results

Between 2011-2017 Current Youth Use of E-Cigarettes Increased: 430% Middle School 894% High School In 2017 more students said they were considering using e-cigarettes in the next year than currently used them Percentage of Students 25 Current E-Cigarette Use and Potential Future Use, NC YTS 23.3 20 15 10 5 0 16.8 16.9 7.7 7 5.3 1 1.7 1.5 2011 2013 2015 2017 2017: Considering Middle School High School Use Next Year 8.7 2017 NORTH C2017 NORTH CAROLINA YOUTH TOBACCO SURVEY RESULTS AROLINA YOUTH TOBACCO SURVEY RESULTS

E-cigarettes are still the #1 product used by youth Use of Tobacco Products in Past 30 Days, NC YTS 2017 E-cigarettes Cigars/cigarillos/little cigars 3.8 5.3 12.7 16.9 Middle School High School Cigarettes 2.5 8.9 Chewing tobacco/snuff/dip 2.3 6.3 Hookah 2.5 4.5 Roll-your-own cigarettes 2.0 3.4 Snus 0.8 3.7 Percentage of Students 2017 NORTH CAROLINA YOUTH TOBACCO SURVEY RESULTS

10% of women who recently had a baby used e-cigarettes in the past 2 years 20 18 16 14 17.5% Use of e-cigarettes in the past 2 years among women who have recently had a baby NC PRAMS, 2016 19% 12 10 8 6 10% 7.6% 5.4% 7.3% 4 2 0 Total Less than 25 years old 25-34 years old Age 35 or over High school education > High school

Of women who used e-cigarettes in past 2 years 64% used during 3 months before pregnancy Use during 3 months before pregnancy 36.3% 18% used during last 3 months of pregnancy Use during last 3 months of pregnancy 82.3% More than once a day Once a day 2-6 days a week 1 day a week or less Did not use e-cigarettes Source: NC Prams 2016

USB-Shaped E-cigarettes

(Stanford University Research into the Impact of Tobacco Advertising, 2018)

JUUL and Other E-cigarettes Market Growth and Concern IN MARCH, 2018, JUUL REPRESENTED 54.6% DOLLAR SHARE OF THE E-CIGARETTE TRADITIONAL RETAIL MARKET. ON APRIL 24 TH, THE FDA REQUESTED THAT JUUL LABS, INC. SUBMIT DOCUMENTS RELATING TO MARKETING PRACTICES AND RESEARCH ON MARKETING, EFFECTS OF PRODUCT DESIGN, PUBLIC HEALTH IMPACT, AND ADVERSE EXPERIENCES AND COMPLAINTS RELATED TO JUUL. Source: Nielsen Total US xaoc/convenience Database and Wells Fargo Securities, LLC

JUULpods and Flavors The product has 5 flavors in pods for the JUUL. These pre-filled JUULpods are sold in the following flavors: Fruit Medley, Virginia Tobacco, Cool Mint, or Crème Brulee, and Mango Each pre-filled pod is equal to about 1 pack of cigarettes. Some reviews of the product suggest about 200 puffs. The JUULpods contain 0.7 ml of e liquid with a very high level of nicotine; 59mg/ml or 5% nicotine by weight.

JUUL Nicotine Delivery 59 mg/ml This graph from PAX Labs shows the rate at which nicotine is absorbed and stays in a test subject s blood. http://vapegrl.com/juul-e-cigarette-review/

Public Health Concerns The concentration of nicotine in JUUL is more than double the concentration found in other e-cigarettes. othis high concentration is a serious concern for youth, who are already uniquely susceptible to nicotine addiction. The addictive potential is so high that the US Surgeon General has declared that youth use of nicotine in any form is unsafe. Educators report that youth are using e-cigarettes on our tobaccofree high school campuses

Nicotine Poses Unique Dangers to the Developing Human Nicotine is toxic to developing fetuses and impairs fetal brain and lung development Nicotine use while adolescent brain is developing can disrupt brain circuit formation Poisonings occur among users via ingestion of nicotine liquid, absorption through skin, and inhalation Source: England, Lucinda J et al. Nicotine and the developing human: A neglected element in the electronic cigarette debate. Am Journ Prev Med 2015.

Among Youth, E-cigarette Use May Lead to Conventional Cigarette Use U.S. adolescents and young adults who had never smoked, but used e- cigarettes at baseline, were 8.3 times more likely to progress to cigarette smoking after 1 year than nonusers of e-cigarettes. Source: US Surgeon General Report, 2016

FDA Actions Related to JUUL and Other E- cigarettes

Source: California Department of Health, www.flavorshookkids.org

Prevention is Critical Successful multicomponent programs prevent young people from starting to use tobacco in the first place and more than pay for themselves in lives and health care dollars saved. Source: US Department of Health and Human Services. 50 Years of Progress: A Report of the Surgeon General, 2014. 2014. Available at: http://www.surgeongeneral.gov/library/reports/50-yearsof-progress/50-years-of-progress-bysection.html.

High School Current Tobacco Use (%) State Spending on Tobacco Prevention and Cessation ($ in millions) 37 35 35.8 High School Tobacco Use and State Spending on Tobacco Use Prevention and Cessation in North Carolina 2001-2017 NC Tobacco free Schools Movement begins 2000 $17.1 $17.1 $17.1 $18.3 $18.3 $17.3 20 18 33 31 29 27 25 23 21 19 17 15 Tobacco Master Settlement Funding for Tobacco begins in NC via HWTF 2002 $0.0 $0.0 33.7% $6.2 $10.9 $15.0 $15.0 28.5% 26.6% 25.8% 25.8% 29.7% $0.0 27.6% $1.2 $1.2 $1.2 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 High School Current Tobacco Use NC Schools 100% Tobacco free 2008 Emergence of e-cigarette use among youth 2011 State Spending on Tobacco Prevention and Cessation In 2014-2016, appropriations for cessation only 28.8 In 2017, $500k non-recurring for tobacco use prevention Since 2001, North Carolina has received an average of $149,825,874 per year from the Tobacco Master Settlement Agreement $2.1 16 14 12 10 8 6 4 2 0

Performance Measures 2018-19: Effective tobacco use prevention messages Education of and organizational involvement of adults who influence youth such as parents, teachers, staff and faculty, health and mental health professionals Number of smoke-free/tobacco free policies, including e-cigarettes, adopted by local governments, colleges, housing, and workplaces Compliance with tobacco-free schools law, tobacco-free child care center rules and tobacco-free college campuses Collaborative efforts to reduce youth access to tobacco products Collaborative efforts to address tobacco use prevention in schools through the Whole Child, Whole School, Whole Community model

QuitlineNC Pregnancy Protocol Woman-centered 10 coaching sessions 7 calls 60-90 days of enrollment 1 call 30 days prior to due date 2 postpartum calls (15 days & 45 days) Relapse prevention sensitivity Structured content for those not ready to quit

2 Karen Caldwell 828-620-1646 Karen.Caldwell@dhhs.nc.gov 3 David Willard 828-264-4995 Northampton Camden Alleghany Rockingham Gates Currituck Ashe Surry Warren Stokes Caswell Person Vance Hertford Pasquotank Halifax Mitchell Watauga Wilkes Granville Perquimans Yadkin Forsyth Orange Avery Guilford Franklin Bertie Chowan Yancey Caldwell Alexander Davie Alamance Durham Nash Madison Edgecombe Washington Burke Iredell Martin Dare Buncombe Davidson Wake Tyrrell Tyrell Haywood McDowell Catawba Randolph Chatham Wilson Swain Rowan Pitt Beaufort Graham Rutherford Lincoln Johnston Hyde Jackson Henderson Lee Greene Cabarrus Gaston Stanly Moore Harnett Cherokee Macon Transylvania Polk Cleveland Wayne Lenoir Montgomery Craven Clay Mecklenburg Pamlico Cumberland Union Anson Richmond Sampson Jones Hoke Duplin Scotland Carteret Onslow Robeson Bladen Pender 1 Tobin Lee 828-349-2480 tobin@mountainwise.org Tobacco Prevention and Control Branch (TPCB) Funds Regions 2015-2020 4 Carleen Crawford 980-314-9142 Carleen.Crawford@mecklenburgcountync.gov 5 Mary Gillett 336-641-6000 David.Willard@apphealth.com Catherine.Mulvihill@wakegov.com mgillett@myguilford.com Lead Counties 6 Ashley Curtice 910-433-3852 acurtice@co.cumberland.nc.us 7 Michelle Mulvihill 919-250-1171 Columbus Brunswick New Hanover 9 Vacant 10 Allyson Moser 252-902-2330 allyson.moser@pittcountync.gov 1. Macon County Public Health 2. Rutherford-Polk-McDowell District Health Department 3. Appalachian District Health Department 4. Mecklenburg County Health Department 5. Guilford County Department of Health and Human Services, Public Health Division 6. Cumberland County Public Health Department 7. Wake County Human Services 8. Robeson County Department of Public Health 9. Albemarle Regional Health Services 10. Pitt County Health Department 8 Ernest Watts 910-334-1488 ernest.watts@hth.co.robeson.nc.us Local Tobacco Coordinators Durham County Health Department Natalie Rich, nrich@dconc.gov Orange County Health Department April Richard, arichard@orangecountync.gov Mecklenburg County Health Department - Kim Bayha, Kimberly.bayha@mecklenburgcountync.gov

For Further Information Contact: Sally Herndon, MPH Branch Head (919) 707-5401 sally.herndon@dhhs.nc.gov Jim Martin, MS Director of Policy and Programs (919) 707-5404 jim.martin@dhhs.nc.gov Jennifer Park, MPH Director of Local Program Development and Regulations (919) 707-5407 jennifer.park@dhhs.nc.gov Ann Staples, MA Director of Communication and Education (704) 543-2347 ann.staples@dhhs.nc.gov Joyce Swetlick, MPH Director of Tobacco Cessation (919) 707-5402 joyce.swetlick@dhhs.nc.gov Steph Gans, LCAS, LCSWA, CTTS Tobacco Treatment Specialist (919) 707-5415 stephanie.gans@dhhs.nc.gov 33

Why is preconception health so important? We now know that ONE-HALF of all infant mortality and morbidity are DIRECTLY RELATED to the health of the mother BEFORE she became pregnant!

Preconception care is Opportunistic Preconception care is for every woman of childbearing age (14-44) every time she is seen Every woman, every time = an opportunity for you to convey important health messages She may not be pregnant this time, but could be the next time you see her Pregnancy Info.net (2018). Childbearing. What are Child Bearing Years? Retrieved from http://www.pregnancy-info.net/childbirthhistory/childbearing.html

Preconception Health: Reproductive Life Planning #1 on the CDC s list of preconception health recommendations is to encourage all men & women of childbearing age to have a reproductive life plan (RLP) #1 goal of an RLP is to reduce unintended pregnancies (47%) and to allow the opportunity to modify risky health behaviors prior to conception Johnson K et al, Recommendations to Improve Preconception Health and Health Care-United States A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care, MMWR Reports and Recommendations, April 21, www.cdc.gov/preconception/index.html

Why are unintended pregnancies a concern? Increased risk for infant morbidity and mortality; including premature birth, low birthweight, and birth defects Increased elective abortion rate Late entry into prenatal care Lack of Mental Health treatment/counseling Higher rates of smoking prior to pregnancy Increased risk of physical abuse and partner relationship ending for mothers Increased child abuse and neglect Increased Medicaid costs Guttmacher Institute (2016). Fact Sheet. Unintended Pregnancy in the United States. https://www.guttmacher.org/sites/default/files/factsheet/fb-unintended-pregnancy-us_0.pdf

Increased infant morbidity and mortality Adverse health conditions Obesity Fetal and neonatal death Neural tube defects Large baby Increased risk for obesity in child Hypertension Pre-term birth Placental abnormalities Birth defects from medications Low birth weight Women with unintended pregnancies may be more likely to have pre-existing medical conditions that adversely affect birth outcomes Poor mental health Sexually Transmitted Infections Diabetes Pre-term birth Low birth weight Miscarriage/Still birth Pre-term birth Birth defects Macrosomia STI Transmission to infant Low birth weight Miscarriage/Still birth Eye infections or blindness Preterm birth Pneumonia Asthma Pre-term birth Low birth weight Small for gestational age Adapted from California Preconception Care Provider training, County of Los Angeles, Department of Public Health, 2003

Increased infant morbidity and mortality Risky health behaviors Tobacco use Low birth weight Small for gestational age Pre-term delivery SIDS Still birth Women who have unintended pregnancies may be more likely to engage in behaviors that negatively impact birth outcomes Alcohol use Preterm birth Birth defects Mental retardation Stillbirth Miscarriage Illicit drug use Fetal death Brain injuries Pre-term birth Developmental problems Birth defects Kost, K., & Lindberg, L. (2015). Pregnancy Intentions, Maternal Behaviors, and Infant Health: Investigating Relationships With New Measures and Propensity Score Analysis. Demography, 52(1), 83 111. http://doi.org/10.1007/s13524-014-0359-9

Desired outcomes: Preconception healthcare that includes tobacco cessation counseling Healthier women and more intended pregnancies Healthier pregnancies and better birth outcomes

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EveryWomanNC.org

Keys to success Rapport building Motivational counseling Progress toward behavior change Goal setting Diane Pearson, Dulce Program, San Diego Family Care

You Quit, Two Quit: Tobacco Cessation For Women of Reproductive Age Megan Canady, MSPH, MSW megancanady@med.unc.edu 919-843-7865 Center for Maternal and Infant Health The University of North Carolina at Chapel Hill 2018 You Quit, Two Quit YouQuitTwoQuit.org

You Quit Two Quit FREE Onsite Training YouQuitTwoQuit.org

Electronic Nicotine Delivery Systems & Perinatal Health YouQuitTwoQuit.org

ENDS & Reproductive Age Women The health effects of using e-cigarettes & other ENDS before or during pregnancy have not been adequately studied Nicotine is a known reproductive toxicant and has adverse effects on fetal development, including lung and brain development The use of smokeless tobacco products, such as snus, during pregnancy has been associated with preterm delivery, stillbirth, and infant apnea Research suggests that women perceive ENDS to be less harmful and less stigmatizing than cigarette use during pregnancy CDC; England, et al. 2016; Mark, et al. 2015 YouQuitTwoQuit.org

ENDS & Poison Control Exposures to e-cigarettes & liquid nicotine can be fatal for infants and young children Even a teaspoon of liquid nicotine can be fatal; smaller amounts can cause severe illness E-cigarette Device & Liquid Nicotine Reported Exposures to Poison Centers 4500 4000 3500 3000 2500 2000 1500 1000 500 0 http://www.aapcc.org/alerts/e-cigarettes/ 2011 2012 2013 2014 2015 2016 2017 YouQuitTwoQuit.org

ENDS Aerosol E-cigarette aerosol is NOT harmless water vapor The CDC has stated that air containing ENDS aerosol is less safe than clean air ENDS use has the potential to involuntarily expose children adolescents, pregnant women, and non-users to aerosolized nicotine, toxic substances and, if the products are altered, to other psychoactive substances. Clean air free of both smoke and ENDS aerosol remains the standard to protect health. YouQuitTwoQuit.org

Tobacco Use and Women of Reproductive Age YouQuitTwoQuit.org

Percentage 30.0 28.0 26.0 24.0 22.0 20.0 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 Women & Tobacco Use in NC, 2016 Current Smoker Ever used ENDS NC State Center for Health Statistics. Available from: http://www.schs.state.nc.us/data/brfss/2016/nc/female/topics.htm#tu YouQuitTwoQuit.org

North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) Survey Results, 2016 1 Asked only of mothers who reported using e-cigarettes or other electronic nicotine products in the past 2 years. 2 Use caution in interpreting cell sizes less than 50. https://schs.dph.ncdhhs.gov/data/prams/2016/ YouQuitTwoQuit.org

Tobacco Use During Pregnancy in NC 1 in 10 babies in NC are born to women reporting tobacco use during pregnancy In some counties over 30% of babies are born to women who smoked YouQuitTwoQuit.org

Tobacco use during pregnancy is directly associated with the top causes of infant mortality in NC YouQuitTwoQuit.org

Tobacco Use Causes Poor Birth & Infant Outcomes Maternal/Fetal Harm From Tobacco Infant/Child Harm From Tobacco o o o o o o o Infertility Miscarriage Ectopic Pregnancy Premature Birth Low Birth Weight Stillbirth SIDS o o o o o SIDS Ear infections Respiratory Infections Asthma Links with childhood obesity, cancer, & attention disorders, and cardiovascular disease & diabetes in adulthood YouQuitTwoQuit.org

Behavior Change & the 5As/5Rs YouQuitTwoQuit.org

The 5 As: Evidence-Based, Best Practice Intervention ASK the patient about her tobacco use status ADVISE her to quit tobacco with personalized messages ASSESS her willingness to quit in next 30 days ASSIST with (pregnancy- and parent-specific, if applicable) self-help materials & social support ARRANGE to follow-up during subsequent visits YouQuitTwoQuit.org

Step 1: Ask 1 Minute Ask your clients: Which of the following statements best describes your *cigarette smoking? A. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime. B. I stopped smoking OVER a year ago. C. I stopped smoking LESS THAN a year ago. D. I smoke, but not every day. E. I smoke daily. * 5As and the Ask was validated referring to cigarette smoking Fiore, et al. 2008; Melvin CL, et al. 2000 YouQuitTwoQuit.org

Step 1: Ask 1 Minute (Pregnant) Ask your pregnant clients: Which of the following statements best describes your cigarette smoking? A. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime. B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. D. I smoke some now, but have cut down on the number of cigarettes I smoke since I found out I was pregnant. E. I smoke regularly now, about the same as I did before I found out I was pregnant. Fiore, et al. 2008; Melvin CL, et al. 2000 YouQuitTwoQuit.org

Step 1: Ask 1 Minute (Postpartum) Ask your postpartum clients: Which of the following statements best describes your cigarette smoking? A. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime. B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. D. I stopped smoking during pregnancy, but I am smoking now. E. I smoked during pregnancy, and I am smoking now. Fiore, et al. 2008; Melvin CL, et al. 2000 YouQuitTwoQuit.org

Screen for Other Tobacco Products Please circle any of the following tobacco products you have used in the past month: Electronic Cigarettes (Juul) Chew Snus Strips Sticks Orbs Lozenges Hookah Cigars/Cigarillos YouQuitTwoQuit.org

Examples of Other Tobacco Products Hookah E-cigarettes and vaping products YouQuitTwoQuit.org

Screen for Second-Hand Exposure Questions for Adults: 1) Does anyone smoke (or vape) in your home? 2) Does anyone smoke (or vape) in your car? 3) Is smoking (or vaping) allowed in your workplace? Questions for Parents/ Caretakers of Children: 1)Does the mother smoke(or vape)? If yes, in the home? In the car? 2) Does the father smoke (or vape)? If yes, in the home? In the car? 3) Is the child exposed to tobacco smoke (or vape) on a regular basis (at least once a week) by anyone other than the parents? Fiore, et al. 2008; Melvin CL, et al. 2000 YouQuitTwoQuit.org

Step 2: Advise 1 Minute Clear, strong, personalized advice to quit Clear: My best advice for you and your baby is for you to quit using tobacco. Strong: Quitting tobacco is one of the most important things you can do to protect your baby and your own health. Personalized: Impact of tobacco use on the baby, the family, and the patient s well being YouQuitTwoQuit.org

Step 3: Assess 1 Minute Assess the patient s willingness to quit within the next 30 days. If a patient responds that she would like to try to quit within the next 30 days, move on to the Assist step. If the patient does not want to try to quit, use the 5 Rs to try to increase her motivation. YouQuitTwoQuit.org

Step 4: Assist 3+ Minutes Suggest and encourage the use of problem-solving methods and skills for tobacco cessation Provide social support as part of the treatment Arrange social support in the patient s environment Provide (pregnancy- and parent-specific, if applicable) self-help tobacco cessation materials Provide a proactive fax referral to the Quitline YouQuitTwoQuit.org

QuitlineNC Perinatal-Specific Services Includes Services for ENDS Use Specialized services for pregnant and postpartum women: Up to 10 calls with relapse prevention sensitivity. One call delivered 30 days prior to due date 2 postpartum contacts (15 & 45 days postpartum) for women who quit Structured content for pregnant tobacco users not ready to quit Specialized services for teens YouQuitTwoQuit.org

Step 5: Arrange 1+ Minute Follow up to monitor progress and provide support Encourage the patient Express willingness to help Ask about concerns or difficulties Invite her to talk about her success YouQuitTwoQuit.org

Employ the 5 Rs RELEVANCE: Help patient figure out the relevant reasons to quit, based on their health, environment, individual situation RISKS: Encourage patient to identify possible negative outcomes to continuing to use tobacco REWARDS: Encourage patient to identify possible benefits to quitting ROADBLOCKS: Work with patient to identify obstacles to quitting and potentially how to overcome them REPETITION: Address the 5Rs with patients at each visit Fiore, et al. 2008 YouQuitTwoQuit.org

Pharmacotherapy to Quit Tobacco YouQuitTwoQuit.org

Public Health Service Guidelines ENDS are NOT an FDA approved means to quit tobacco use Non-pregnant adults are more likely to quit when using a combination of brief counseling and pharmacotherapy Behavioral intervention is first-line treatment in pregnant women o Pharmacotherapy has not been sufficiently tested for efficacy or safety in pregnant patients o May be necessary for heavy tobacco users Fiore, et al. 2008; USPSTF, 2015 YouQuitTwoQuit.org

FDA-Approved Pharmacotherapies for Adults Nicotine Replacement Products All forms of NRT are Pregnancy Category D Nicotine Patch Nicotine Gum Lozenge Nicotine Nasal Spray Nicotine Inhaler Non-Nicotine Prescription Medications Bupropion SR (Pregnancy Category C) Varenicline (Pregnancy Category C) YouQuitTwoQuit.org

Nicotine Replacement During Lactation Lactation Risk Category: L2 Limited Data Compatible Nicotine Patch (non-prescription) Constant dose 21 mg transdermal patch results in nicotine equivalent to smoking 17 cigarettes daily passing into breastmilk 7mg & 14mg patches result in proportionately lower amounts in breastmilk Nicotine Gum/Lozenge (non-prescription) Amount of nicotine that passes into breastmilk is variable, depending on the amount chewed/dissolved Nicotine Inhaler (prescription only) Maternal plasma concentrations are about 1/3 of those of smokers, so breastmilk concentrations are probably proportionately less as well LACTMED; Hale, 2014. YouQuitTwoQuit.org

Bupropion and Varenicline During Lactation Bupropion Lactation risk category: L3 Limited Data Probably Compatible AAP: Drugs whose effect on nursing infants is unknown but may be of concern Peak milk level occurs 2 hrs. after a 100mg dose this milk level provides 0.66% of the maternal dose Anecdotal reports of reduction in milk supply after beginning bupropion Should not be used in mothers and infants prone to seizures Varenicline Lactation risk category: L4 No Data - Possibly Hazardous AAP: Not reviewed Very little information available There are concerns about its long half-life (24 hrs.) In animal studies, the drug was transferred to nursing pups LACTMED; Hale, 2014. YouQuitTwoQuit.org

Tools for Providers, Clinics, & Patients YouQuitTwoQuit.org

YouQuitTwoQuit.org YouQuitTwoQuit.org YouQuitTwoQuit.org

78 Perinatal Patient Education Materials: Booklets (English and Spanish) YouQuitTwoQuit.org

Perinatal Patient Education Materials: Handouts (English & Spanish) YouQuitTwoQuit.org

Perinatal Patient Education Materials: Handouts (English & Spanish) YouQuitTwoQuit.org

Provider 5As/5Rs Pocket Card YouQuitTwoQuit.org

Ordering Materials Order these FREE resources by going to this link https://whb.ncpublichealth.com/provpart/pubmanbro.htm and click the Publications Form. Look at the end of page 3 under Tobacco Cessation and fax in your order. YouQuitTwoQuit.org

YQ2Q Practice Bulletin Includes the following resources: 5As algorithm Evidence-based screening questions How to make a proactive referral to QuitlineNC Billing for cessation counseling Rx during pregnancy & lactation E-cigarette info Trauma-informed tobacco care http://tinyurl.com/yq2q2017 YouQuitTwoQuit.org

Perinatal Patient Education Materials: Posters (English & Spanish) YouQuitTwoQuit.org

References 85 Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health. Information for Health Care Providers and Public Health Professionals: Preventing Tobacco Use During Pregnancy. Available from: http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/providers.html Chamberlain, C., O'Mara-Eves, A., Oliver, S., Caird, J. R., Perlen, S. M., Eades, S. J., & Thomas, J. (2013). Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database Syst Rev, 10, CD001055. doi:10.1002/14651858.cd001055.pub4 Coleman, T., Chamberlain, C., Davey, M. A., Cooper, S. E., & Leonardi-Bee, J. (2015). Pharmacological interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev, 12, CD010078. doi:10.1002/14651858.cd010078.pub2 Curtin, S.C., Matthews, T.J. (2016). Smoking prevalence and cessation before and during pregnancy: data from the birth certificate, 2014. National Vital Statistics Report, 65, 1-14. England LJ, Tong VT, Koblitz A, Kish-Doto J, Lynch MM, Southwell BG. (2016). Perceptions of emerging tobacco products and nicotine replacement therapy among pregnant women and women planning a pregnancy. Prev Med Rep. 2016 Dec; 4: 481-85. Fiore, M.C., Jaen C.R., Baker, T.B., Bailey, W. C., Benowitz, N. L., Curry, S. J., Wewers, M. E. (2008). Treating tobacco use and dependence: 2008 update - clinical practice guidelines. Rockville, MD: U.S. Department of Health and Human Services, PublicHealth Service, Agency for Healthcare Research and Quality. Hale T. Medications and Mothers Milk 2014. Hale Publishing, 2014. Haug NA, Stitzer ML, Svikis DS. Smoking during pregnancy and intention to quit: a profile of methadone-maintained women. Nicotine & Tobacco Research. November 1, 2001 2001;3(4):333-339. Jones HE, Heil S, O'Grady K, et al. Smoking in pregnant women screened for an opioid agonist medication study compared to related pregnant and non-pregnant patient samples. The American journal of drug and alcohol abuse. 2009;35(5):375-380. Jones HE, Heil SH, Tuten M, Chisolm MS, Foster JM, O'Grady KE, Kaltenbach K. Cigarette smoking in opioid-dependent pregnant women: neonatal and maternal outcomes. Drug Alcohol Depend. 2013; 131(3):271-7. LACTMED: Drug and Lactation Database. National Institutes of Health. Nicotine.. Available from: http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~rogz0y:1 Mark KS, Farquhar B, Chisolm MS, Coleman-Cowger VH, Terplan M. Knowledge, Attitudes, and Practice of Electronic Cigarette Use Among Pregnant Women. J Addict Med. 2015 Jul- Aug;9(4):266-72. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL.. Recommended cessation counselling for pregnant women who smoke: A review of the evidence. Tob Contr, 2000 9 Suppl 3:III80-4. YouQuitTwoQuit.org

References, cont. 86 N.C. State Center for Health Statistics, Hospital Discharge Data, 2004-2014 Quinn G, Ellison BB, Meade C, Roach CN, Lopez E, Albrecht T, Brandon TH. Adapting smoking relapse-prevention materials for pregnant and postpartum women: formative research. Matern Child Health J. 2006 May;10(3):235-45. Ripley-Moffatt CE, et al. Safe Babies: A Qualitative Analysis of the Determinants of Postpartum Smoke-Free and Relapse States. Nicotine Tob Res. 2008; 10(8):1355-64. Su, A., Buttenheim, A.M. (2014). Maintenance of smoking cessation in the postpartum period: which interventions work best in the long-term? Matern Child Health J, 18, 714-728. Tong, V. T., Dietz, P. M., Morrow, B., D'Angelo, D. V., Farr, S. L., Rockhill, K. M. (2013). Trends in smoking before, during, and after pregnancy--pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000-2010. MMWR Surveill Summ, 62(6), 1-19. Tong, V.T., Jones, J.R., Dietz, P.M., D Angelo, D., Bombard, J.M. (2009). Trends in smoking before, during, and after pregnancy pregnancy risk assessment monitoring system (PRAMS), United States, 31 sites, 2000 2005. MMWR, 58, 1-29. Winklbaur B, Baewert A, Jagsch R, Rohrmeister K, Metz V, Aeschbach Jachmann C, Thau K, Fischer G. Association between prenatal tobacco exposure and outcome of neonates born to opioid-maintained mothers. Implications for treatment. Eur Addict Res. 2009; 15(3):150 6. U.S. Department of Health and Human Services, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health (Ed.). The health consequences of smoking - 50 years of progress: a report of the Surgeon General. 2014. US Preventive Service s Task Force. Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. Sept 2015. Available from: https://www.uspreventiveservicestaskforce.org/page/document/updatesummaryfinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1 WHO. (2013). World Health Organization (WHO) Recommendations for the Prevention and Management of Tobacco Use and Second-Hand Smoke Exposure in Pregnancy. Retrieved from http://apps.who.int/iris/bitstream/10665/94555/1/9789241506076_eng.pdf YouQuitTwoQuit.org

Postpartum Relapse Nearly 2/3 of women who quit smoking during pregnancy relapse within one year Postpartum smoking relapse rates may be as high as 80%, and of those who relapse: 45% resume smoking at two to three months, and up to 60-70% by six months Relapse may be delayed or avoided among women who receive smoking cessation counseling during the postpartum period McBride CM et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:706-11. 5. Smoking during pregnancy United States, 1990 2002. MMWR Morb Mortal Wkly Rep. 2004;53(39):911 5: Scheibmeir M, O'Connell KA. In harm's way: childbearing women and nicotine. J Obstet Gynecol Neonatal Nurs. 1997;26:477 84.; Ershoff DH, Quinn VP, Mullen PD. Relapse prevention among women who stop smoking early in pregnancy: a randomized clinical trial of a self-help intervention. Am J Prev Med. 1995;11:178 84.

Preventing Postpartum Relapse Good documentation Use the 5 A s at the postpartum visit Use positive language to counsel Reiterate messages of: Risks to babies and children from smoke and vape exposure Make your home a TOBACCO-FREE ZONE Praise for efforts to quit and stay quit for the individual

Treating Postpartum Relapse Reassure and encourage her to try again Review Triggers Refer back to QuitlineNC and self help materials Ensure patient has a medical home

March of Dimes North Carolina Preconception Health Campaign A statewide initiative aimed at improving birth outcomes in NC by reaching out to women with important health messages before they become pregnant Formerly functioned as the NC Folic Acid Campaign Goals of the Campaign are to reduce infant mortality, birth defects, premature birth, and chronic health conditions in women, while also aiming to increase intended pregnancies in NC Seeks to raise awareness and inspire positive action among the general public, health care professionals, and community agencies

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Thank you! Brenda W. Stubbs Jennifer Vickery Triad Region Coordinator Western Region Coordinator bstubbs@marchofdimes.org Jennifer.Vickery@msj.org 336-580-1779 828-785-3344 For more information about the Campaign and other preconception health topics visit: EveryWomanNC.org and at Latinasana.org Follow us on Facebook and Twitter: @everywomannc