Helping Pregnant Women Cope With Smoking Cessation

M. Elena Mendoza, John F. Chaves, PhD

Topics in Advanced Practice Nursing eJournal. 2003;3(4)

Abstract and Introduction

Smoking is associated with well-documented threats to health and well being. Pregnancy presents an unusually important time to initiate smoking cessation strategies because of the motivation of the mother to protect her fetus and the opportunity to provide a significant health benefit to both the fetus and the mother at the same time. The emotional support and encouragement provided by an empathic nurse, coupled with specific strategies to strengthen motivation and help patients cope with the cessation process, can contribute to a successful outcome.

According to the Centers for Disease Control and Prevention,^[1] smoking contributes to more than 450,000 deaths per year and is the primary cause of preventable morbidity, mortality, and health expense in the United States. During 1995-1999, smoking caused approximately $157 billion in annual health-related economic losses.^[2] During this period of time, smoking caused an annual average of 264,087 deaths among men and 178,311 deaths among women in the United States, most of them attributed to lung cancer (124,813), ischemic heart disease (81,976), and chronic airways obstruction (64,735).^[2] Total annual smoking-attributable mortality estimates include the deaths of 589 males and 377 females by residential fire during 1994-1998,^[3] and the additional deaths of 15,517 males and 22,536 females from lung cancer and heart disease attributable to exposure to secondhand smoke.^[4]

This year alone, lung cancer will kill nearly 68,000 US women. That is 1 in every 4 cancer deaths among women, and about 27,000 more deaths than from breast cancer (41,000). In 1999, approximately 165,000 women died prematurely from smoking-related diseases, like cancer and heart disease. Women also face unique health effects from smoking such as problems related to pregnancy.^[5] In the United States, of the 4 million women who deliver infants each year, approximately 0.8-1 million smoke during their pregnancies.^[6] This fact resulted in the death of 599 male and 408 female infants annually during 1995-1999.^[2]

Pregnant women may be uniquely motivated toward smoking cessation due to its effect on the fetus. Both pharmaceutical and behavioral strategies for smoking cessation are reviewed here. A case example is given to illustrate behavioral intervention with a pregnant woman.

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Cite this: Helping Pregnant Women Cope With Smoking Cessation - Medscape - Oct 29, 2003.

Abstract and Introduction
Smoking Risks in Pregnancy
Assessment of Smoking Behavior and Motivation to Quit
Therapeutic Approaches
Case Study
Summary and Clinical Implications
References

Table 1. Pharmacologic Interventions for Smoking Cessation
Product		Daily Dose	Duration of Treatment	Use in Pregnancy	Availability	Common Side Effects
*First-line Medications*
*NRT*	Transdermal patch --24 hour (eg, Nicoderm CQ) --16 hour (eg, Nicotrol)	7-, 14-, or 21-mg patch worn for 24 hours^* 15-mg patch worn for 16 hours	8 weeks 8 weeks	FDA Pregnancy Category D^§	Over the counter	Skin reactions, insomnia, wild dreams
	Nicotine gum (Nicorette) --2 mg (< 25 cigarettes/day) --4 mg (≥ 25 cigarettes/day)	1 piece/hour (do not exceed 24 pieces per day)	8-12 weeks	FDA Pregnancy Category D	Over the counter	Mouth irritation, sore jaws, dyspepsia, hiccups
	Vapor inhaler (Nicotrol Inhaler)	6-16 cartridges/day delivered dose, 4 mg/cartridge)	3-6 months	FDA Pregnancy Category D	Prescription only	Mouth and throat irritation, cough
	Nasal spray (Nicotrol NS)	1-2 doses/hour (1 mg total) (maximum 40 mg/day)	3-6 months	FDA Pregnancy Category D	Prescription only	Nasal irritation; sneezing, cough, teary eyes
	Nicotine polacrilex lozenge --2 mg (time to first cigarette > 30 minutes) --4 mg (time to first cigarette ≤ 30 minutes)	1 lozenge every 1-2 hours (do not exceed 20 lozenges a day)	12 weeks	FDA Pregnancy Category D	Over the counter	Heartburn, nausea, hiccups
*NNT*	Sustained-released bupropion (Zyban or Wellbutrin SR)	150 mg/day for 3 days, then 150 mg twice a day	7-12 weeks (up to 6 months to maintain abstinence)	FDA Pregnancy Category B	Prescription only	Insomnia, dry mouth, agitation
*Second-line Medications*
*NNT*	Clonidine	Initial dosing is typically 0.1 mg orally twice a day or 0.1 mg/day transdermally increasing by 0.1 mg/day per week if needed	From 3 to 10 weeks	FDA Pregnancy Category C	Prescription only	Dry mouth, drowsiness, dizziness, sedation, constipation
*NNT*	Nortriptyline	Starting at a dose of 25 mg and increasing gradually to a target dose of 75-100 mg/day	12 weeks	FDA Pregnancy Category C	Prescription only	Sedation, dry mouth, blurred vision, urinary retention, lightheadedness, shaky hands

NRT, nicotine replacement therapy; NNT, nonnicotine therapy
^*Starting dose is 21 mg per day; if smoker weighs less than 100 lb or smokes fewer than 10 cigarettes per day, starting dose is 14 mg per day. Maintain starting dose for 4 weeks and then decrease dose every week until it is stopped.
Treatment with bupropion should be begun 1-2 weeks the quit date.
Treatment with clonidine should be started shortly before (up to 3 days) or on the quit date.
^§Category D = positive evidence of human fetal risk but the benefits may outweigh the risks; Category C = animal studies have shown an adverse effect on the fetus; there are no adequate studies in humans but the benefits may outweigh the risks; or there are no animal studies or adequate human studies; Category B = animal studies have failed to show a risk to the fetus but there are no adequate studies in pregnant women; or animal studies have shown an adverse effect but human studies have not shown a risk to the fetus in the first trimester and there is no evidence of risk in later trimesters.

Table 2. Tips for Treatment
Session	Activities
Session I	1. Describe some medical benefits for maternal and fetal health. 2. Teach patients how to self-record smoking and the situations triggering smoking. 3. Advise patients to write down the benefits of cessation on a card and read them every time they feel an urge to smoke. 4. Advise patients not to have packs of cigarettes or ashtrays easily visible (stimulus control). 5. Assignments: self-record the smoking behavior, read the card with the benefits, and stimulus control.
Session II	1. Review the assignments. 2. Explore feelings and thoughts related to wanting to smoke and teach some strategies to relax such as deep breathing or muscle relaxation and ways to change irrational thoughts. 3. Advise ranking of cigarettes smoked in order of less to more difficulty of resisting to smoke them. 4. Encourage patients to set a date to quit smoking. 5. Suggest saving money not spent on cigarettes to use as a reward. 6. Assignments: try not to smoke those cigarettes which are easiest to avoid, and go on with the assignments of session I.
Session III	1. Review the assignments. 2. Educate about the withdrawal syndrome. 3. Teach some relapse prevention techniques. 4. Give general recommendations about health and how to maintain abstinence.

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Helping Pregnant Women Cope With Smoking Cessation

Abstract and Introduction

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Tables

References

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Authors and Disclosures

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