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A simple, effective method that midwives can use to help pregnant women stop smoking
A SIMPLE, EFFECTIVE METHOD THAT MIDWIVES CAN USE TO HELP PREGNANT WOMEN STOP SMOKING Lorraine V. Klerman,
DrPH
and Judith P. Rooks,
ABSTRACT Recent studies suggest that few maternity care providers are offering the assistance that women need to reduce or stop smoking during pregnancy. This is probably because of a lack of conviction among providers that they can be effective, a perception that they lack counseling skills, and the absence of reimbursement for counseling and self-help materials. Midwives have strong counseling skills and materials will soon be available that can help them and others become trained smoking counselors. Thus, midwives can easily adopt the techniques that have been shown effective in reducing or stopping smoking during pregnancy. These are a 5- to 10minute counseling session at the first prenatal visit by a trained provider plus appropriate print materials (pregnancy-specific and culturally- and reading-level-appropriate). Guiding the smoker to select a date for quitting and checking on smoking status at each visit increase the likelihood of behavior change. These techniques should increase the quit rate, over spontaneous quitting, by 10%–20%. Managed care organizations looking for ways to reduce costly hospitalizations for low birth weight infants or ambulatory care visits for smoking-related illnesses in infants and children should support this intervention. Medicaid and tobacco settlement funds are potential sources of reimbursement for counseling and educational materials. q 1999 by the American College of Nurse-Midwives.
Despite increasing evidence that many female smokers can be persuaded to stop or reduce smoking while they are pregnant, studies indicate that most maternity care providers do not seriously attempt to bring about this behavior change. A recent analysis of the National Ambulatory Medical Care Study revealed that officebased physicians identified the patients’ smoking status in 81% of pregnancy-related visits but counseled women about smoking during only 22% of the pregnant smokers’ visits (1). Studies of primary care physicians in North Carolina (2), and obstetricians in Texas (3) have also found that physicians counsel only some of their patients, including those seeking prenatal care. Three reasons are usually given for not actively assisting pregnant smokers to quit: 1) lack of conviction that anything the provider can do will result in change in behavior, 2) the perception among providers that they lack counseling skills, and 3) the absence of reimbursement for
Address correspondence to Lorraine V. Klerman, Department of Maternal and Child Health, University of Alabama at Birmingham, Ryals Building, Suite 320, Birmingham, AL 35294-0022.
118 q 1999 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
CNM, MPH, FACNM
providing smoking-related counseling and educational materials. This article suggests ways to reduce these barriers to effective smoking cessation/reduction activities. ADVERSE CONSEQUENCES OF SMOKING DURING AND AFTER PREGNANCY
Smoking during pregnancy is associated with a large number of adverse consequences for the fetus, infant, and child. Women who smoke are more likely to abort spontaneously and to deliver a low birth weight infant (4). The low birth weight may either be due to preterm labor and birth or to intrauterine growth retardation. (A recent article by Ward includes an excellent description of the pathophysiology that results in these outcomes [5]). Other conditions that are more common among smokers include placenta abruption, placenta previa, and premature rupture of the membranes. It is estimated that low birth weight would decrease by 19% if all women stopped smoking (6). A recent study suggested that, during early pregnancy, even passive smoking (ie, the inhaling of the smoke created by others) can increase the risk of small for gestational age infants (7). Infants born to smoking mothers are more likely to die from sudden infant death syndrome (SIDS) (8), in addition to the elevated infant mortality associated with immaturity and restricted uterine growth. One estimate suggests that each year, maternal cigarette smoking is responsible for 19,000 –141,000 spontaneous abortions, 32,000 – 61,000 low birth weight infants, 1,900 – 4,800 deaths from perinatal disorders, 14,000 –26,000 admissions to neonatal intensive care units, and 1,200 – 2,200 deaths from SIDS (9). In their first and subsequent years, children of smoking mothers are more likely to suffer from respiratory infections, including bronchitis and pneumonia, and from asthma and otitis media. Smoking during pregnancy and/or environmental tobacco smoke exposure may affect pulmonary function in childhood (10). Research has also found evidence of neurobehavioral disturbances in the newborns of smoking women and attention-deficit hyperactivity disorderlike behavior, behavior problems, and conduct disorder in children (11). One study found that daughters of mothers who smoked during pregnancy were more likely to smoke as adolescents, even if their mothers were no longer smoking. The researchers suggested that smok-
Journal of Nurse-Midwifery • Vol. 44, No. 2, March/April 1999 0091-2182/99/$20.00 • PII S0091-2182(99)00031-2
ing during pregnancy changes the brain chemistry in some permanent way that makes it easier for the child to become addicted (12). PREVALENCE OF SMOKING AMONG PREGNANT WOMEN
Although, according to birth certificate data, the number of women who smoke during pregnancy dropped by more than a quarter between 1990 and 1996, over 400,000 pregnant women smoked in 1996. In 1995 and 1996, smoking rates actually increased among pregnant teenagers (13). In 1994 through 1996, 20.6% of pregnant 15– 44year-old women interviewed for the National Household Survey on Drug Abuse (NHSDA) reported that they had smoked cigarettes during the previous month. Smoking rates were higher among younger (15–25 years of age) than older women (26 – 44 years of age), were higher among white, non-Hispanic women than among black, non-Hispanic women, and were lowest among Hispanic women. Never-married, divorced, separated, and widowed women were more likely to smoke than currently married ones. Smoking declined markedly with increasing education and decreased as pregnancy progressed; 26.5% of the respondents reported smoking in the first trimester, 20.2% in the second, and 17.3% in the third (14). The rates reported by the NHSDA are much higher than those reported on birth certificates. According to the 1996 birth certificates, 13.6% of births were to women who smoked (based on 46 states, the District of Columbia, and New York City, but excluding California, Indiana, South Dakota, and the remainder of New York State, which did not report this information on their birth certificates) (13). It is generally assumed that birth certificate data underestimate maternal smoking because the individuals who complete the certificates do not always have access to accurate information about smoking and because pregnant women and new mothers who smoke sometimes deny it. Also, because birth certificate data do not include California, they are particularly likely to be inaccurate in respect to smoking among Hispanic and Asian or Pacific Islander women.
Lorraine V. Klerman is a professor in the Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham. She serves as Associate Director of the Smoke-Free Families program, sponsored by the Robert Wood Johnson Foundation. Judith P. Rooks is a midwife and epidemiologist in private practice as a consultant. She is an Associate of the Pacific Institute for Women’s Health, which is based in Los Angeles, and has an ongoing consultative role with the Maternity Center Association in New York City.
Several studies have revealed a relatively high rate of “spontaneous quitting” among pregnant women. About a fifth of women who smoked before they became pregnant stop smoking when they learn that they are pregnant, many before their first prenatal visit (15). The challenge to maternity care providers is to maintain these “spontaneous quitters” as non-smokers throughout their pregnancies and after they give birth, and to help women who are still smoking to stop or significantly reduce smoking. About a third of women who stop smoking early in pregnancy start smoking again before delivery (16) and over two thirds may resume smoking after delivery (17). This is particularly unfortunate because smoking appears to have its greatest deleterious effect on fetal growth during the third trimester (18). MIDWIVES AND PREGNANT SMOKERS
Smoking cessation/reduction activities are a “natural” for midwives, as professionals who emphasize education and supporting women so that they can make changes in their lifestyles that are conducive to health. Moreover, it is particularly important for midwives to learn effective ways to help women stop smoking because many midwives serve populations characterized by higher than average rates of smoking. Midwives care for disproportionately large numbers of teenagers and American Indian women (19 –21). The rate of smoking among pregnant teenagers is higher than that in other age groups and is rising, while the rate is falling in other age groups. Also, the rate of smoking during pregnancy is higher among American Indian women than among women of other racial/ethnic groups and declined the least between 1990 and 1996, showing little change since 1993 (13). One study found that women whose births were attended by certified nurse-midwives in hospitals during 1989 had a rate of smoking above the national average. This was not true for midwife-attended births at home or in birth centers (22). THE DEVELOPMENT OF AN APPROACH TO SMOKING CESSATION/REDUCTION
Many researchers have developed and tested ways to help pregnant women reduce or stop smoking. A metaanalysis of randomized trials of prenatal smoking cessation interventions found a 50% increase in smoking cessation among the women exposed to interventions as compared to controls. Most of the programs studied used an individual counseling session of no more than 10 minutes conducted by counselors who had received special training for that purpose. All used printed materials, especially self-help manuals, designed specifically for pregnant women (23). Smoke-Free Families, a national research and dissem-
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ination program supported by the Robert Wood Johnson Foundation, has produced similar results. SmokeFree Families funded eleven small research projects designed to stop or reduce smoking during pregnancy or in the postpartum period. Some were relatively simple, for example, counseling by a nurse or case manager. Others were technologically sophisticated, for example, interactive videos, personal digital assistants, or computerized telephone counseling systems. This group of studies not only confirmed the finding that brief counseling plus self-help materials designed for pregnant smokers can make a difference, but also found that longer and more elaborate interventions did not significantly improve the rate of smoking cessation/reduction, with two exceptions. Financial incentives for the pregnant women and their supporters increased smoking cessation/reduction, as did frequent testing of urine cotinine levels with written and verbal feedback of the results. The findings from both of these new interventions, however, should be replicated before others are advised to use them. During 1999, Smoke-Free Families, in collaboration with the Robert Wood Johnson Foundation, three federal agencies (the Agency for Health Care Policy and Research [AHCPR], the Centers for Disease Control and Prevention [CDC], and the Health Resources and Services Administration), and the American College of Obstetricians and Gynecologists, will mount a large-scale campaign to make all maternity care providers aware that there is something that they can do to reduce smoking among pregnant women who are light or moderate smokers—something that is simple, effective, and within their ability to manage, even in a busy office or clinic. (Light smokers are usually defined as those who smoke less than 11 cigarettes a day; moderate smokers, 11–20 per day; and heavy smokers, 21 or more per day.) The approach builds on the Clinical Practice Guidelines of the AHCPR (24). The campaign will state that for women smoking at the first prenatal visit, the provision of a single 5- to 10-minute counseling session by a trained provider plus appropriate print educational materials can increase quit rates by 10%–20%. The collaborating agencies sponsoring this approach believe that an individual can become adequately trained in the counseling method by using self-instructional training materials. The total time needed for this training should be less than 3 hours. The collaborating agencies are committed to preparing such training materials, which will be available to all who are interested. A SIMPLE APPROACH TO SMOKING CESSATION/ REDUCTION
The approach that is being promoted by Smoke-Free Families and the collaborating organizations is 5–10
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minutes of counseling by a trained counselor (the maternity care provider, a nurse, social worker, nutritionist, or other member of the office staff) and printed, educational materials. The printed materials should include a self-help manual designed specifically for pregnant smokers that is culturally appropriate for the woman and suitable for her reading level. Counselors should consider offering educational materials designed for household members as well. For this approach to work, the maternity care provider must identify the women who are still smoking when they are seen for the first time. Determination of smoking status should be considered one of the “vital signs” and be ascertained as routinely as blood pressure or blood sugar (25). To accomplish this, it may be necessary to modify clinical records forms by adding lines for information about smoking at initial and follow-up visits. (A study of a sample of low-risk pregnant women cared for by family physicians, nurse-midwives, and obstetricians in Washington State found that urban certified nurse-midwives were significantly more likely than either type of physician to record information on smoking at the first prenatal visit [26].) Maternity care providers are more likely to obtain accurate information about the pregnant woman’s smoking status if they ask a comprehensive question such as, “Which of the following statements best describes your cigarette smoking? Would you say: 1. I smoke regularly now—about the same amount as before finding out I was pregnant. 2. I smoke regularly now, but I’ve cut down since I found out I was pregnant. 3. I smoke every once in a while. 4. I have quit smoking since finding out I was pregnant. 5. I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes.” (A similar questionnaire was used by Quinn et al in their research [16].) Although all pregnant women should be asked about their smoking status, several studies have found that many smokers deny smoking, perhaps because of shame or social pressure. This denial is particularly likely to occur when the woman has been urged by her maternity care provider or a family member to stop or reduce smoking. Thus, biochemical confirmation of self-reported smoking status by urine or saliva testing should be considered a routine clinical practice. Most private offices and clinical practices ask women to consent to a number of tests as a regular part of their first prenatal visit. Adding a test for cotinine should add little to the cost of the test battery. Urine and saliva testing by a simple, dipstick-like method is already available, and the validity of this measure will probably be improved in the next few years.
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After determining that a woman smokes, the primary maternity care provider should briefly indicate her or his concern about smoking during pregnancy and then may decide to ask the patient to see the smoking counselor, who may be a nurse, social worker, or member of the office staff. Many midwives would probably prefer, however, to include counseling about smoking as part of their interaction with their clients. The midwife or smoking counselor would need to spend 5–10 minutes with the smoker, determining the amount smoked, reviewing smoking-associated risks to fetus, infant, and mother, discussing the benefits of stopping smoking, teaching methods to stop smoking, asking for a commitment to stop smoking, and encouraging the use of a self-help manual that will be provided. This counseling should help patients recognize the importance of stopping or reducing their smoking and assist them to take the action needed. During this session, the midwife or smoking counselor should introduce the smoker to a self-help manual designed specifically for pregnant women and appropriate for her racial or ethnic group and her reading level. The midwife or smoking counselor might also urge the smoker to set a date for quitting. The maternity care provider should verbally reinforce the smoking cessation message during every subsequent visit. Placing a special sticker on the cover of the prenatal record of past or present smokers will remind the provider to ask about smoking at each visit in order to support women who have stopped or are trying to stop smoking and to help those who have not yet reached this point to begin to consider it. Smoke-Free Families reviewed the educational materials currently available for pregnant smokers and prepared a brochure describing the best of them (27). This brochure is being updated by the American College of Obstetricians and Gynecologists and will soon be available. Midwives, nurses, and physicians are also urged to read the professionally oriented, smoking-related publications of the AHCPR, Smoking Cessation: Clinical Practice Guidelines; Smoking Cessation: Information for Specialists; Smoking Cessation: A Systems Approach; and Helping Smokers Quit: A Guide for Primary Care Clinicians. (These materials can be obtained, free of charge, by calling 800-358-9259 or writing the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Springs, MD 20907. The documents are also available online at http://www.ahcpr.gov.)
SOURCES OF FINANCIAL SUPPORT
Even though the number of pregnant smokers is declining, providing the remaining ones with counseling and self-help manuals could be a financial problem for some practices; but because the pregnancy-related conditions and childhood diseases associated with maternal smok-
ing increase the cost of medical care, a benefit-cost argument can be made. The CDC estimate that the smoking-attributable costs of complicated births in 1995 were $1.4 billion, based on a smoking prevalence of 19% during pregnancy. This is 11% of the costs for all complicated births (28). The CDC also calculated that if smoking cessation counseling was available to all pregnant smokers, there would be a net savings in neonatal intensive care unit (NICU) hospitalization of almost $78 million, and that would mean a savings of $3.31 for every $1.00 spent on the program. When the costs of providing long-term care for infants with disabilities secondary to low birth weight are added to the NICU costs, $6.00 is saved for every dollar spent on smoking cessation programs (29). Midwives who work in managed care settings should have available and use evidence about these benefits to convince their employers that the small cost of the additional counseling time and educational materials necessary to persuade a significant number of pregnant smokers to reduce or stop smoking is a good investment. And although most efforts to change unhealthy behaviors do not result in savings until years into the future, efforts to help pregnant women stop smoking can produce significant savings within a year. Midwives who provide maternity care to Medicaideligible women should check with their state Medicaid agency to determine whether smoking cessation/reduction counseling and patient education materials are Medicaid-reimbursable expenses. If they are not, the local chapter of the American College of Nurse-Midwives should join with other interested groups in lobbying for having such counseling and educational materials covered by their state Medicaid program. Also, the recent settlement between the tobacco companies and the states should make a large amount of money available not only for the prevention of smoking among youth, but also for treatment of smoking among adults. Pregnant smokers are the most important group to reach because of the two lives involved. One possible use of these tobacco settlement funds would be to reimburse maternity care providers for the cost of providing smoking cessation/reduction counseling and educational materials to pregnant smokers. If a state had 80,000 births per year and the rate of smoking among its pregnant women was the same as the rate for the United States as a whole (20%–25%), the state would only have between 16,000 and 20,000 pregnant smokers a year. If the per-patient cost of the intervention was $50, including payment for training time, time spent in counseling, and educational materials, reimbursing the providers would cost the state less than $1 million per year. Most states would easily save this much due to the reduction of low birth weight infants needing expensive, specialized care under Medicaid. Bringing a portion of
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the tobacco settlement funds to maternity care providers who treat pregnant smokers will also probably require lobbying.
ing for reimbursement for these activities through Medicaid and tobacco settlement funds.
CONCLUSIONS
Preparation of this article was made possible by grants from the Robert Wood Johnson Foundation and from the federal Maternal and Child Health Bureau (MCJ 9040). Assistance with this manuscript by Robert L. Goldenberg, MD, and H. Pennington Whiteside, MSPH, is gratefully acknowledged.
As noted in the beginning of this article, the three reasons usually given for not actively assisting pregnant smokers to quit are: 1) lack of conviction that anything the provider can do will result in change in behavior, 2) the perception among providers that they lack counseling skills, and 3) the absence of reimbursement for providing smoking-related counseling and educational materials. Research has demonstrated that the first reason is wrong. Maternity care providers, especially midwives, can bring about this behavior change. They may not be able to convert all pregnant smokers into exsmokers, but that is an unrealistic goal; and maternity care providers should not allow the perfect to be the enemy of the good! Even though not every pregnant woman can be convinced to stop or significantly reduce smoking (and heavy smokers especially are a problem), the techniques suggested in this article can prevent several thousand low birth weight births. They should be used. The second reason, lack of counseling skills, should not be relevant to midwives, for whom counseling is a primary method of treatment. Some physicians, however, may decide to have another individual in the office or clinic assigned to the counseling. In the near future, training materials will be available to qualify not only midwives and physicians, but also nurses, social workers, and others to offer the most up-to-date methods of smoking cessation/reduction counseling to pregnant smokers. Even if the counseling is done by someone else, however, the primary maternity care provider, regardless of how busy, should retain responsibility for identifying pregnant smokers, for initially discussing with them the need for stopping smoking, and for continually reinforcing this message. Modifying the third reason, the absence of reimbursement, may take a bit longer. Managed care organizations are increasing their prevention-oriented activities, and smoking cessation/reduction should certainly be among them. Some state Medicaid agencies are already considering reimbursing Medicaid-certified providers for counseling pregnant smokers. Use of a small segment of the tobacco settlement money to reimburse all private offices and clinics for such counseling and for educational materials would undoubtedly hasten the day when all pregnant women received these essential services. Midwives can take the lead in bringing smoking cessation/reduction techniques to pregnant smokers by adopting these techniques themselves, by urging other maternity care providers to adopt them, and by advocat-
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REFERENCES 1. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998;279: 604 – 8. 2. Centers for Disease Control and Prevention. Counseling practices of primary care physicians—North Carolina, 1991. MMWR 1992;41:565– 8. 3. Mullen PD, Pollak KI, Titus JP, Sockrider MM, Moy JG. Prenatal smoking cessation counseling by Texas obstetricians. Birth 1998; 25:25–31. 4. Walsh RA. Effects of maternal smoking on adverse pregnancy outcomes: examination of the criteria of causation. Human Biology 1994;66:1059 –92. 5. Ward S. Addressing nicotine addiction in women: Role of the midwife. J Nurse Midwifery 1999;44:3–18. 6. Kleinman JC, Madans JH. The effects of maternal smoking, physical stature, and educational attainment on the incidence of low birth weight. Am J Epidemiol 1985;121:843–55. 7. Dejin-Karlsson E, Hanson BS, Ostergren P-O, Sjoberg N-O, Marsal K. Does passive smoking in early pregnancy increase the risk of small for gestational age infants? Am J Public Health 1998;88: 1523–7. 8. Schoendorf KC, Kiely JL. Relationship of sudden infant death syndrome to maternal smoking during and after pregnancy. Pediatrics 1992;90:905– 8. 9. DiFranza JR, Lew RA. Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome. J Fam Pract 1995;40:385–94. 10. Cunningham J, Dockery DW, Speizer FE. Maternal smoking during pregnancy as a predictor of lung function in children. Am J Epidemiol 1994;139:1139 –52. 11. Olds D. Tobacco exposure and impaired development: a review of the evidence. Ment Retard Devel Disabilities Res Rev 1997;3:257– 69. 12. Kandel DB, Wu P, Davies M. Maternal smoking during pregnancy and smoking by adolescent daughters. Am J Public Health 1994;84:1407–13. 13. Mathews TJ. Smoking during pregnancy, 1960 –1996. National Center for Health Statistics. Vital Health Statistics Series No. 47 (10), 1998. 14. Substance Abuse and Mental Health Administration, Office of Applied Studies. National Household Survey on Drug Abuse: main findings 1996. Rockville (MD): U.S. Dept. of Health and Human Services, 1996. 15. LeClere FB, Wilson JB. Smoking behavior of recent mothers, 18 – 44 years of age, before and after pregnancy: United States, 1990. Advance data from vital and health statistics; No. 288. Hyattsville (MD): National Center for Health Statistics, 1997. 16. Quinn VP, Mullen PD, Ershoff DH. Women who stop smoking spontaneously prior to prenatal care and predictors of relapse before delivery. Addict Behav 1991;16:29 – 40.
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17. Fingerhut LA, Kleinman JC, Kendrick JS. Smoking before, during, and after pregnancy. Am J Public Health 1990;80:541– 4. 18. Lieberman E, Gremy I, Lang JM, Cohen AP. Low birthweight at term and the timing of fetal exposure to maternal smoking. Am J Public Health 1994;84:1127–31. 19. Declercq ER. Where babies are born and who attends their births: findings from the revised 1989 United States standard certificate of live birth. Obstet Gynecol 1993;81:997–1004. 20. Parker JD. Ethnic differences in midwife-attended U.S. births. Am J Public Health 1994;84:1139 – 41. 21. Rooks JP. Midwifery and childbirth in America. Philadelphia: Temple University Press, 1997. 22. Declerq ER. Midwifery care and medical complications: the role of risk screening. Birth 1995;22:68 –73. 23. Dolan-Mullen P, Ramirez G, Groff JY. A meta-analysis of randomized trials of prenatal smoking cessation interventions. Am J Obstet Gynecol 1994;171:1328 –34. 24. Agency for Health Care Policy and Research. Smoking Cessation. Clinical Practice Guideline Number 18. Washington (DC): U.S.
Government Printing Office, 1996. (AHCPR Publication No. 96-0692.) 25. Fiore MC. The new vital sign: assessing and documenting smoking status. JAMA 1991;266:3183– 4. 26. Baldwin L-M, Raine T, Jenkins LD, Hart LG, Rosenblatt R. Do providers adhere to ACOG standards? The case of prenatal care. Obstet Gynecol 1994;84:549 –56. 27. Smoke-Free Families Technical Assistance and Dissemination Project. (Project Directors: SE Winders, JM Raczynski, Department of Health Behavior, University of Alabama at Birmingham) Healthy moms. Healthy babies. Healthy families. Helping your patients quit smoking. Madison (WI): Wisconsin Clearinghouse for Prevention Resources, 1997 (out of print). 28. Centers for Disease Control and Prevention. Medical care expenditures attributable to cigarette smoking during pregnancy—United States, 1995. MMWR 1997;46:1048 –50. 29. Marks JS, Koplan JP, Hogue CJR, Dalmat ME. A cost-benefit/ cost-effectiveness analysis of smoking cessation for pregnant women. Am J Prev Med 1990;6:282–9.
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DrPH
and Judith P. Rooks,
ABSTRACT Recent studies suggest that few maternity care providers are offering the assistance that women need to reduce or stop smoking during pregnancy. This is probably because of a lack of conviction among providers that they can be effective, a perception that they lack counseling skills, and the absence of reimbursement for counseling and self-help materials. Midwives have strong counseling skills and materials will soon be available that can help them and others become trained smoking counselors. Thus, midwives can easily adopt the techniques that have been shown effective in reducing or stopping smoking during pregnancy. These are a 5- to 10minute counseling session at the first prenatal visit by a trained provider plus appropriate print materials (pregnancy-specific and culturally- and reading-level-appropriate). Guiding the smoker to select a date for quitting and checking on smoking status at each visit increase the likelihood of behavior change. These techniques should increase the quit rate, over spontaneous quitting, by 10%–20%. Managed care organizations looking for ways to reduce costly hospitalizations for low birth weight infants or ambulatory care visits for smoking-related illnesses in infants and children should support this intervention. Medicaid and tobacco settlement funds are potential sources of reimbursement for counseling and educational materials. q 1999 by the American College of Nurse-Midwives.
Despite increasing evidence that many female smokers can be persuaded to stop or reduce smoking while they are pregnant, studies indicate that most maternity care providers do not seriously attempt to bring about this behavior change. A recent analysis of the National Ambulatory Medical Care Study revealed that officebased physicians identified the patients’ smoking status in 81% of pregnancy-related visits but counseled women about smoking during only 22% of the pregnant smokers’ visits (1). Studies of primary care physicians in North Carolina (2), and obstetricians in Texas (3) have also found that physicians counsel only some of their patients, including those seeking prenatal care. Three reasons are usually given for not actively assisting pregnant smokers to quit: 1) lack of conviction that anything the provider can do will result in change in behavior, 2) the perception among providers that they lack counseling skills, and 3) the absence of reimbursement for
Address correspondence to Lorraine V. Klerman, Department of Maternal and Child Health, University of Alabama at Birmingham, Ryals Building, Suite 320, Birmingham, AL 35294-0022.
118 q 1999 by the American College of Nurse-Midwives Issued by Elsevier Science Inc.
CNM, MPH, FACNM
providing smoking-related counseling and educational materials. This article suggests ways to reduce these barriers to effective smoking cessation/reduction activities. ADVERSE CONSEQUENCES OF SMOKING DURING AND AFTER PREGNANCY
Smoking during pregnancy is associated with a large number of adverse consequences for the fetus, infant, and child. Women who smoke are more likely to abort spontaneously and to deliver a low birth weight infant (4). The low birth weight may either be due to preterm labor and birth or to intrauterine growth retardation. (A recent article by Ward includes an excellent description of the pathophysiology that results in these outcomes [5]). Other conditions that are more common among smokers include placenta abruption, placenta previa, and premature rupture of the membranes. It is estimated that low birth weight would decrease by 19% if all women stopped smoking (6). A recent study suggested that, during early pregnancy, even passive smoking (ie, the inhaling of the smoke created by others) can increase the risk of small for gestational age infants (7). Infants born to smoking mothers are more likely to die from sudden infant death syndrome (SIDS) (8), in addition to the elevated infant mortality associated with immaturity and restricted uterine growth. One estimate suggests that each year, maternal cigarette smoking is responsible for 19,000 –141,000 spontaneous abortions, 32,000 – 61,000 low birth weight infants, 1,900 – 4,800 deaths from perinatal disorders, 14,000 –26,000 admissions to neonatal intensive care units, and 1,200 – 2,200 deaths from SIDS (9). In their first and subsequent years, children of smoking mothers are more likely to suffer from respiratory infections, including bronchitis and pneumonia, and from asthma and otitis media. Smoking during pregnancy and/or environmental tobacco smoke exposure may affect pulmonary function in childhood (10). Research has also found evidence of neurobehavioral disturbances in the newborns of smoking women and attention-deficit hyperactivity disorderlike behavior, behavior problems, and conduct disorder in children (11). One study found that daughters of mothers who smoked during pregnancy were more likely to smoke as adolescents, even if their mothers were no longer smoking. The researchers suggested that smok-
Journal of Nurse-Midwifery • Vol. 44, No. 2, March/April 1999 0091-2182/99/$20.00 • PII S0091-2182(99)00031-2
ing during pregnancy changes the brain chemistry in some permanent way that makes it easier for the child to become addicted (12). PREVALENCE OF SMOKING AMONG PREGNANT WOMEN
Although, according to birth certificate data, the number of women who smoke during pregnancy dropped by more than a quarter between 1990 and 1996, over 400,000 pregnant women smoked in 1996. In 1995 and 1996, smoking rates actually increased among pregnant teenagers (13). In 1994 through 1996, 20.6% of pregnant 15– 44year-old women interviewed for the National Household Survey on Drug Abuse (NHSDA) reported that they had smoked cigarettes during the previous month. Smoking rates were higher among younger (15–25 years of age) than older women (26 – 44 years of age), were higher among white, non-Hispanic women than among black, non-Hispanic women, and were lowest among Hispanic women. Never-married, divorced, separated, and widowed women were more likely to smoke than currently married ones. Smoking declined markedly with increasing education and decreased as pregnancy progressed; 26.5% of the respondents reported smoking in the first trimester, 20.2% in the second, and 17.3% in the third (14). The rates reported by the NHSDA are much higher than those reported on birth certificates. According to the 1996 birth certificates, 13.6% of births were to women who smoked (based on 46 states, the District of Columbia, and New York City, but excluding California, Indiana, South Dakota, and the remainder of New York State, which did not report this information on their birth certificates) (13). It is generally assumed that birth certificate data underestimate maternal smoking because the individuals who complete the certificates do not always have access to accurate information about smoking and because pregnant women and new mothers who smoke sometimes deny it. Also, because birth certificate data do not include California, they are particularly likely to be inaccurate in respect to smoking among Hispanic and Asian or Pacific Islander women.
Lorraine V. Klerman is a professor in the Department of Maternal and Child Health, School of Public Health, University of Alabama at Birmingham. She serves as Associate Director of the Smoke-Free Families program, sponsored by the Robert Wood Johnson Foundation. Judith P. Rooks is a midwife and epidemiologist in private practice as a consultant. She is an Associate of the Pacific Institute for Women’s Health, which is based in Los Angeles, and has an ongoing consultative role with the Maternity Center Association in New York City.
Several studies have revealed a relatively high rate of “spontaneous quitting” among pregnant women. About a fifth of women who smoked before they became pregnant stop smoking when they learn that they are pregnant, many before their first prenatal visit (15). The challenge to maternity care providers is to maintain these “spontaneous quitters” as non-smokers throughout their pregnancies and after they give birth, and to help women who are still smoking to stop or significantly reduce smoking. About a third of women who stop smoking early in pregnancy start smoking again before delivery (16) and over two thirds may resume smoking after delivery (17). This is particularly unfortunate because smoking appears to have its greatest deleterious effect on fetal growth during the third trimester (18). MIDWIVES AND PREGNANT SMOKERS
Smoking cessation/reduction activities are a “natural” for midwives, as professionals who emphasize education and supporting women so that they can make changes in their lifestyles that are conducive to health. Moreover, it is particularly important for midwives to learn effective ways to help women stop smoking because many midwives serve populations characterized by higher than average rates of smoking. Midwives care for disproportionately large numbers of teenagers and American Indian women (19 –21). The rate of smoking among pregnant teenagers is higher than that in other age groups and is rising, while the rate is falling in other age groups. Also, the rate of smoking during pregnancy is higher among American Indian women than among women of other racial/ethnic groups and declined the least between 1990 and 1996, showing little change since 1993 (13). One study found that women whose births were attended by certified nurse-midwives in hospitals during 1989 had a rate of smoking above the national average. This was not true for midwife-attended births at home or in birth centers (22). THE DEVELOPMENT OF AN APPROACH TO SMOKING CESSATION/REDUCTION
Many researchers have developed and tested ways to help pregnant women reduce or stop smoking. A metaanalysis of randomized trials of prenatal smoking cessation interventions found a 50% increase in smoking cessation among the women exposed to interventions as compared to controls. Most of the programs studied used an individual counseling session of no more than 10 minutes conducted by counselors who had received special training for that purpose. All used printed materials, especially self-help manuals, designed specifically for pregnant women (23). Smoke-Free Families, a national research and dissem-
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ination program supported by the Robert Wood Johnson Foundation, has produced similar results. SmokeFree Families funded eleven small research projects designed to stop or reduce smoking during pregnancy or in the postpartum period. Some were relatively simple, for example, counseling by a nurse or case manager. Others were technologically sophisticated, for example, interactive videos, personal digital assistants, or computerized telephone counseling systems. This group of studies not only confirmed the finding that brief counseling plus self-help materials designed for pregnant smokers can make a difference, but also found that longer and more elaborate interventions did not significantly improve the rate of smoking cessation/reduction, with two exceptions. Financial incentives for the pregnant women and their supporters increased smoking cessation/reduction, as did frequent testing of urine cotinine levels with written and verbal feedback of the results. The findings from both of these new interventions, however, should be replicated before others are advised to use them. During 1999, Smoke-Free Families, in collaboration with the Robert Wood Johnson Foundation, three federal agencies (the Agency for Health Care Policy and Research [AHCPR], the Centers for Disease Control and Prevention [CDC], and the Health Resources and Services Administration), and the American College of Obstetricians and Gynecologists, will mount a large-scale campaign to make all maternity care providers aware that there is something that they can do to reduce smoking among pregnant women who are light or moderate smokers—something that is simple, effective, and within their ability to manage, even in a busy office or clinic. (Light smokers are usually defined as those who smoke less than 11 cigarettes a day; moderate smokers, 11–20 per day; and heavy smokers, 21 or more per day.) The approach builds on the Clinical Practice Guidelines of the AHCPR (24). The campaign will state that for women smoking at the first prenatal visit, the provision of a single 5- to 10-minute counseling session by a trained provider plus appropriate print educational materials can increase quit rates by 10%–20%. The collaborating agencies sponsoring this approach believe that an individual can become adequately trained in the counseling method by using self-instructional training materials. The total time needed for this training should be less than 3 hours. The collaborating agencies are committed to preparing such training materials, which will be available to all who are interested. A SIMPLE APPROACH TO SMOKING CESSATION/ REDUCTION
The approach that is being promoted by Smoke-Free Families and the collaborating organizations is 5–10
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minutes of counseling by a trained counselor (the maternity care provider, a nurse, social worker, nutritionist, or other member of the office staff) and printed, educational materials. The printed materials should include a self-help manual designed specifically for pregnant smokers that is culturally appropriate for the woman and suitable for her reading level. Counselors should consider offering educational materials designed for household members as well. For this approach to work, the maternity care provider must identify the women who are still smoking when they are seen for the first time. Determination of smoking status should be considered one of the “vital signs” and be ascertained as routinely as blood pressure or blood sugar (25). To accomplish this, it may be necessary to modify clinical records forms by adding lines for information about smoking at initial and follow-up visits. (A study of a sample of low-risk pregnant women cared for by family physicians, nurse-midwives, and obstetricians in Washington State found that urban certified nurse-midwives were significantly more likely than either type of physician to record information on smoking at the first prenatal visit [26].) Maternity care providers are more likely to obtain accurate information about the pregnant woman’s smoking status if they ask a comprehensive question such as, “Which of the following statements best describes your cigarette smoking? Would you say: 1. I smoke regularly now—about the same amount as before finding out I was pregnant. 2. I smoke regularly now, but I’ve cut down since I found out I was pregnant. 3. I smoke every once in a while. 4. I have quit smoking since finding out I was pregnant. 5. I wasn’t smoking around the time I found out I was pregnant, and I don’t currently smoke cigarettes.” (A similar questionnaire was used by Quinn et al in their research [16].) Although all pregnant women should be asked about their smoking status, several studies have found that many smokers deny smoking, perhaps because of shame or social pressure. This denial is particularly likely to occur when the woman has been urged by her maternity care provider or a family member to stop or reduce smoking. Thus, biochemical confirmation of self-reported smoking status by urine or saliva testing should be considered a routine clinical practice. Most private offices and clinical practices ask women to consent to a number of tests as a regular part of their first prenatal visit. Adding a test for cotinine should add little to the cost of the test battery. Urine and saliva testing by a simple, dipstick-like method is already available, and the validity of this measure will probably be improved in the next few years.
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After determining that a woman smokes, the primary maternity care provider should briefly indicate her or his concern about smoking during pregnancy and then may decide to ask the patient to see the smoking counselor, who may be a nurse, social worker, or member of the office staff. Many midwives would probably prefer, however, to include counseling about smoking as part of their interaction with their clients. The midwife or smoking counselor would need to spend 5–10 minutes with the smoker, determining the amount smoked, reviewing smoking-associated risks to fetus, infant, and mother, discussing the benefits of stopping smoking, teaching methods to stop smoking, asking for a commitment to stop smoking, and encouraging the use of a self-help manual that will be provided. This counseling should help patients recognize the importance of stopping or reducing their smoking and assist them to take the action needed. During this session, the midwife or smoking counselor should introduce the smoker to a self-help manual designed specifically for pregnant women and appropriate for her racial or ethnic group and her reading level. The midwife or smoking counselor might also urge the smoker to set a date for quitting. The maternity care provider should verbally reinforce the smoking cessation message during every subsequent visit. Placing a special sticker on the cover of the prenatal record of past or present smokers will remind the provider to ask about smoking at each visit in order to support women who have stopped or are trying to stop smoking and to help those who have not yet reached this point to begin to consider it. Smoke-Free Families reviewed the educational materials currently available for pregnant smokers and prepared a brochure describing the best of them (27). This brochure is being updated by the American College of Obstetricians and Gynecologists and will soon be available. Midwives, nurses, and physicians are also urged to read the professionally oriented, smoking-related publications of the AHCPR, Smoking Cessation: Clinical Practice Guidelines; Smoking Cessation: Information for Specialists; Smoking Cessation: A Systems Approach; and Helping Smokers Quit: A Guide for Primary Care Clinicians. (These materials can be obtained, free of charge, by calling 800-358-9259 or writing the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Springs, MD 20907. The documents are also available online at http://www.ahcpr.gov.)
SOURCES OF FINANCIAL SUPPORT
Even though the number of pregnant smokers is declining, providing the remaining ones with counseling and self-help manuals could be a financial problem for some practices; but because the pregnancy-related conditions and childhood diseases associated with maternal smok-
ing increase the cost of medical care, a benefit-cost argument can be made. The CDC estimate that the smoking-attributable costs of complicated births in 1995 were $1.4 billion, based on a smoking prevalence of 19% during pregnancy. This is 11% of the costs for all complicated births (28). The CDC also calculated that if smoking cessation counseling was available to all pregnant smokers, there would be a net savings in neonatal intensive care unit (NICU) hospitalization of almost $78 million, and that would mean a savings of $3.31 for every $1.00 spent on the program. When the costs of providing long-term care for infants with disabilities secondary to low birth weight are added to the NICU costs, $6.00 is saved for every dollar spent on smoking cessation programs (29). Midwives who work in managed care settings should have available and use evidence about these benefits to convince their employers that the small cost of the additional counseling time and educational materials necessary to persuade a significant number of pregnant smokers to reduce or stop smoking is a good investment. And although most efforts to change unhealthy behaviors do not result in savings until years into the future, efforts to help pregnant women stop smoking can produce significant savings within a year. Midwives who provide maternity care to Medicaideligible women should check with their state Medicaid agency to determine whether smoking cessation/reduction counseling and patient education materials are Medicaid-reimbursable expenses. If they are not, the local chapter of the American College of Nurse-Midwives should join with other interested groups in lobbying for having such counseling and educational materials covered by their state Medicaid program. Also, the recent settlement between the tobacco companies and the states should make a large amount of money available not only for the prevention of smoking among youth, but also for treatment of smoking among adults. Pregnant smokers are the most important group to reach because of the two lives involved. One possible use of these tobacco settlement funds would be to reimburse maternity care providers for the cost of providing smoking cessation/reduction counseling and educational materials to pregnant smokers. If a state had 80,000 births per year and the rate of smoking among its pregnant women was the same as the rate for the United States as a whole (20%–25%), the state would only have between 16,000 and 20,000 pregnant smokers a year. If the per-patient cost of the intervention was $50, including payment for training time, time spent in counseling, and educational materials, reimbursing the providers would cost the state less than $1 million per year. Most states would easily save this much due to the reduction of low birth weight infants needing expensive, specialized care under Medicaid. Bringing a portion of
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the tobacco settlement funds to maternity care providers who treat pregnant smokers will also probably require lobbying.
ing for reimbursement for these activities through Medicaid and tobacco settlement funds.
CONCLUSIONS
Preparation of this article was made possible by grants from the Robert Wood Johnson Foundation and from the federal Maternal and Child Health Bureau (MCJ 9040). Assistance with this manuscript by Robert L. Goldenberg, MD, and H. Pennington Whiteside, MSPH, is gratefully acknowledged.
As noted in the beginning of this article, the three reasons usually given for not actively assisting pregnant smokers to quit are: 1) lack of conviction that anything the provider can do will result in change in behavior, 2) the perception among providers that they lack counseling skills, and 3) the absence of reimbursement for providing smoking-related counseling and educational materials. Research has demonstrated that the first reason is wrong. Maternity care providers, especially midwives, can bring about this behavior change. They may not be able to convert all pregnant smokers into exsmokers, but that is an unrealistic goal; and maternity care providers should not allow the perfect to be the enemy of the good! Even though not every pregnant woman can be convinced to stop or significantly reduce smoking (and heavy smokers especially are a problem), the techniques suggested in this article can prevent several thousand low birth weight births. They should be used. The second reason, lack of counseling skills, should not be relevant to midwives, for whom counseling is a primary method of treatment. Some physicians, however, may decide to have another individual in the office or clinic assigned to the counseling. In the near future, training materials will be available to qualify not only midwives and physicians, but also nurses, social workers, and others to offer the most up-to-date methods of smoking cessation/reduction counseling to pregnant smokers. Even if the counseling is done by someone else, however, the primary maternity care provider, regardless of how busy, should retain responsibility for identifying pregnant smokers, for initially discussing with them the need for stopping smoking, and for continually reinforcing this message. Modifying the third reason, the absence of reimbursement, may take a bit longer. Managed care organizations are increasing their prevention-oriented activities, and smoking cessation/reduction should certainly be among them. Some state Medicaid agencies are already considering reimbursing Medicaid-certified providers for counseling pregnant smokers. Use of a small segment of the tobacco settlement money to reimburse all private offices and clinics for such counseling and for educational materials would undoubtedly hasten the day when all pregnant women received these essential services. Midwives can take the lead in bringing smoking cessation/reduction techniques to pregnant smokers by adopting these techniques themselves, by urging other maternity care providers to adopt them, and by advocat-
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