ORLANDO, Florida ― A significant knowledge gap about smoking cessation practices among perinatal substance abuse staff at a single center means pregnant women are often not being counseled about the dangers of tobacco and encouraged to quit, new research suggests.

Perinatal substance abuse counselors from the Johns Hopkins Center for Addiction and Pregnancy in Baltimore, Maryland, fared significantly worse than substance abuse staff who worked in Veteran's Administration hospital centers, other hospital-based centers, and community counseling centers throughout the United States.

"We found that they had much less knowledge about smoking cessation practices, and they also were more likely to have negative attitudes about their ability to get these women to stop smoking," senior author Margaret Chisolm, MD, from the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, in Baltimore, told Medscape Medical News.

The findings were presented here at the American Society of Addiction Medicine (ASAM) 45th Annual Medical-Scientific Conference.

More Harmful Than Illicit Drugs

Nearly 21% of reproductive-age women in the United States smoke cigarettes, and about 13% continue to smoke during pregnancy. This percentage is as high as 90% among pregnant women with substance use disorders, Dr. Chisolm said.

"When I started working here in 2006, this issue literally hit me in the face. These pregnant women who are in our drug abuse program would smoke outside the hospital in between their group sessions, and things like that, so I wanted to know why we were not addressing this in our program, especially since smoking is the leading modifiable risk factor for pregnancy-related morbidity and mortality," she said.

"Smoking is as harmful, if not more harmful, than most of the illicit drugs that pregnant women use," Dr. Chisolm added.

In the study, Dr. Chisolm used the Smoking Knowledge, Attitudes, and Practices (S-KAP) Instrument to compare the knowledge, attitudes, and practices among the 41 perinatal substance abuse staff at her institution with the knowledge, attitudes, and practices among 335 general substance abuse treatment staff from 11 other institutions.

The S-KAP Instrument was developed by Kevin L. Delucchi, PhD, and colleagues from the University of California, San Francisco, and published in the Journal of Drug Issues.

The instrument elicits staff knowledge about the risks of smoking, attitudes toward treating nicotine dependence in the context of drug abuse treatment, and practices used to address smoking among patients being treated for drug abuse. It also asks about staff awareness of possible barriers to providing relevant services for smoking cessation.

The general substance abuse workers included 56 substance abuse staff from the US Department of Veterans Affairs (VA), 101 staff from other hospital-based settings, and 178 staff from community-based settings.

"Our hypothesis was that our perinatal drug abuse counselors would actually do better than staff counseling nonpregnant substance abusers elsewhere because smoking during pregnancy is such a big problem, but in fact, they did worse on all measures except 1," Dr. Chisolm said.

Significant differences were seen between the Johns Hopkins perinatal program staff and the staff in the other treatment settings on all S-KAP scales, including knowledge (P = .01), attitudes (P = .001), and practices (P = .001).

The only measure in which the perinatal program staff did significantly better than the staff in the other treatment settings was barriers to care (P < .001).

"I think that our staff thought there would be no barriers to care because they know that all pregnant women are insured to get smoking cessation treatment," Dr. Chisolm said.

"We are a hospital-based program, and our staff is well educated, so it is not as if we have an uneducated, poor staff," she said. "We've got to do better for our pregnant smokers because even if you can't get people to stop beyond pregnancy, just getting them to stop during pregnancy is an immense benefit to the child."

Dr. Chisolm also gave kudos to the VA for its efforts at incorporating smoking cessation practises into its substance abuse treatment programs.

"The VA does very well. They have put a lot of effort into training their staff and making smoking cessation a priority in substance abuse treatment programs. Their system might be worth emulating," she said.

Surprising Finding

"It should go without saying that substance use during pregnancy places the user, the pregnancy, and the developing fetus at risk," Gavin Bart, MD, PhD, from the University of Minnesota, in Minneapolis, and director of the Division of Addiction Medicine at Hennepin County Medical Center, told Medscape Medical News.

"What is surprising here is that those treatment programs specializing in perinatal addiction care scored worse on nicotine knowledge and treatment practice than programs not specializing in pregnancy.

"The reasons for this are unclear but could reflect a heightened focus on other drugs during pregnancy under a common but misinformed perception that, in the face of drug addiction, smoking is a lesser priority and can be placed on the back burner," Dr. Bart, who was not part of the study, said.

Another factor may be a sense of treatment futility in that there are few effective nicotine treatment options approved for use during pregnancy, he suggested.

"And finally, I think that the findings also speak highly for how a systematic approach to guidance and policy within a healthcare system such as the VA may be a useful model for improving knowledge and attitudes and breaking down barriers to treatment for nicotine addiction during pregnancy."

Dr. Chisolm and Dr. Bart report no relevant financial relationships.

American Society of Addiction Medicine (ASAM) 45th Annual Medical-Scientific Conference. Poster 2. Presented April 11, 2014.


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