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Women and smoking: patterns, health effects, and treatments
WOMEN AND SMOKING: PATTERNS, HEALTH EFFECTS, AND TREATMENTS Karen Siener, MPH, Ann Malarcher, PhD, MSPH, and Corinne Husten, MD, MPH
Tobacco use remains the number one cause of preventable death among women in the United States. Of particular concern to obstetricians and gynecologists is the morbidity caused by tobacco use and by exposure to secondhand smoke among women of childbearing age, pregnant women, and their newborns. Women who smoke have lower fertility rates and are more likely to experience negative side effects from oral contraceptives. Pregnant women who smoke are more likely to suffer miscarriages and to have low birth weight and preterm babies, and infants with sudden infant death syndrome. Over one of every four women aged 18 to 44 smoke in the U.S. Unfortunately, at least 14% of women smoke during pregnancy. The good news is that research shows that tobacco treatment interventions by health care providers can increase the number of patients who successfully quit. The Agency for Health Care Policy and Research developed recommendations and guidelines to assist health care providers to integrate a tobacco treatment intervention into an office setting. It is recommended that every physician 1) ask patients about their tobacco use; 2) advise them to stop using tobacco; 3) assist patients interested in cessation efforts; and From the Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and the Cardiovascular Health Branch, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
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4) arrange appropriate follow-up. (Prim Care Update Ob/Gyns 2000; 7:77– 84. © 2000 Elsevier Science Inc. All rights reserved.)
Physicians can make a difference in their patients’s use of tobacco. However, some physicians are reluctant to treat tobacco use due to time constraints, perceived lack of effective skills, frustration with low success rates, or feeling that tobacco counseling is not a priority. This article reviews current trends in cigarette smoking among women, health effects of tobacco use, the effectiveness of brief patient counseling, and the importance of intensive treatment interventions for pregnant women. For most patients, a brief counseling session can be effective, time-efficient, and rewarding for both the physician and the patient.
Prevalence of Cigarette Smoking WOMEN Data from the 1997 National Health Interview Survey, conducted by the National Center for Health Statistics indicate that over 22 million women (22%) smoke, including 14 million women of reproductive age.1 Smoking prevalence is highest among women 25– 44 years of age (26%) and among those with 9 –11 years of education (30%). Among racial and ethnic groups, American Indian and Alaska Native women
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have the highest smoking prevalence (31%), followed by white and African American women (23– 33%). Hispanic (14%) and Asian and Pacific Islander women (12%) have the lowest smoking prevalence. In the 1990s, there has been little change in smoking prevalence.1 In terms of amount of smoking, data from the National Health Interview Survey, conducted by the National Center for Health Statistics, indicate that white women are more likely to be heavy smokers than black or Hispanic women, and highly educated women are the least likely to be heavy smokers.
PREGNANT WOMEN Based on information from birth certificates, smoking during pregnancy has declined from 18% in 1990 to 13% in 1997.2 This decline was observed for all racial and ethnic groups. American Indian, white, and Hawaiian women continue to have the highest prevalence of smoking during pregnancy. Women aged 15–19 years currently have the highest rates of smoking during pregnancy (18%), and smoking in this age group increased in both 1995, 1996 and 1997. The number of cigarettes smoked per day by pregnant women declined from 1990 to 1996. However, caution must be used in interpreting birth certificate data because pregnant women probably underreport smoking to their clinicians. Data from household surveys suggest that 22% of women smoke during pregnancy.2
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ADOLESCENT GIRLS Unfortunately, in contrast to trends among women, smoking among girls increased dramatically in the 1990s until 1998, when a decrease was observed in the Monitoring the Future Study conducted by the University of Michigan. In 1999, 33% of 12th-grade girls, 26% of 10th-grade girls, and 18% of 8th-grade girls were current smokers (defined as smoking in the last 30 days). Smoking prevalence was higher for girls than boys until the late 1980s; since then, gender differences in smoking have been small.
Other Tobacco Products Women and girls are less likely to use other tobacco products then men and boys, respectively. In 1998, data from the National Household Survey on Drug Abuse (NHSDA), conducted by the National Institute on Drug Abuse, indicate that 16% of women reported ever smoking a cigar and 2% of women had smoked a cigar in the past month. Recent estimates of past-month cigar smoking among girls are conflicting and range from 3% (in the NHSDA) to 10% (in the 1999 National Youth Tobacco Survey conducted by the Centers for Disease Control and Prevention). Smokeless tobacco use among women has remained low (⬍2%).1
Quitting Behavior WOMEN In 1997, 19.2 million women were former smokers.1 The proportion of ever-smokers who have quit increases with age and is higher for white than African American women, and for women with 16 or more years of education.1 The probabilities of attempting to quit and succeeding are comparable for women and men. Unfortunately, quitting is not easier for adoles78
cents; although many adolescent girls who are regular smokers attempt to quit, most are unsuccessful.3
PREGNANT WOMEN In 1990, 23% of pregnant women quit after learning of their pregnancy; the percentage of women who quit during pregnancy increased as level of education increased.4 Pregnant women generally quit because of concerns about adverse fetal outcomes. Unfortunately, many women appear to consider cessation during pregnancy as a temporary abstinence: up to 75% of mothers resume smoking within 6 months after delivery.4 Postpartum relapse appears to be unrelated to educational level.4
Determinants RISK FACTORS FOR INITIATION AMONG ADOLESCENTS Self-esteem, self-image, psychological health, and attitudes and beliefs about the utility of smoking are important determinants of adolescent smoking.3 Several studies of adolescents have found relationships between smoking and body image, body weight, and dieting behavior.3 For example, girls aged 12–18 years who smoke are more likely than nonsmokers to believe that smoking helps keep weight down and to be attempting weight loss.3 Smoking among adolescent girls is associated with alcohol and drug abuse, early sexual relations, poor school achievement, and dropping out of school.3 Cigarette smoking may be viewed as a method of coping with anxiety, frustration, or other psychological distress induced by lack of academic success or other environmental stressors.3 Participation in organized sports and religion are protective for ciga-
rette smoking, as they may serve as alternatives for dealing with stress.3 Smoking behavior is also influenced by parental, sibling, and peer smoking; the adolescent’s perceptions of norms and expectations for smoking; the societal acceptability of smoking; and the availability of cigarettes.3 The tobacco industry, through advertising and promotions, has had a major influence on the acceptability of smoking for girls and women. One of the first major marketing efforts directed at women began in the 1920s: the American Tobacco Company’s Lucky Strike campaign featured the slogan “Reach for a Lucky Instead of a Sweet.” The themes of smoking and slenderness and smoking and liberation have been continually used by the tobacco industry in its marketing to women. For example, the Virginia Slims brand was launched with a 100 mm “slimmer than usual” cigarette and the “You’ve Come a Long Way, Baby!” slogan in 1968. A study of smoking trends among girls and women identified two major periods of increased initiation among girls and young women: one in the mid1920s coincident with the Lucky Strike women’s marketing campaigns, and one in the late 1960s coincident with large-scale marketing of women’s brands.5 In 1995, cigarette advertising and promotional expenditures were almost $5 billion, making cigarettes one of the most heavily marketed products in the U.S.1
NICOTINE ADDICTION Many girls and women who smoke are addicted to nicotine. The pharmacologic and behavioral processes that determine nicotine addiction are similar to those that determine addiction to other drugs, such as heroin and cocaine.6 Nicotine tolerance develops such that repeated use results in diminished effects and can be accompanied by inPrim Care Update Ob/Gyns
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creased intake. Physical dependence on nicotine is characterized by a withdrawal syndrome during tobacco abstinence. Withdrawal symptoms include increased appetite; depressed mood; insomnia; inability to concentrate; irritability, frustration, or anger; anxiety; restlessness; and craving for tobacco. In 1991 and 1992 about 75% of women smokers 25 years of age and older reported feeling dependent on cigarettes, 78% reported being unable to cut down on their smoking, and 35% reported feeling sick when they tried to cut down on their smoking.7 Even light smokers reported these indicators of nicotine dependence: among women smoking five or fewer cigarettes per day, 43% felt dependent on cigarettes, 54% felt unable to cut down on their smoking, and 22% felt sick when they tried to cut down on their smoking. Women are more likely than men to smoke in states of negative affect or stress.8 In addition, a history of depression is a strong risk factor for the prevalence and severity of nicotine addiction. The greater prevalence of major depression in women than men may enhance the vulnerability of women to nicotine addiction and may lead to a poorer response to smoking cessation treatment.8 Some studies indicate that smoking rates, nicotine withdrawal symptoms, and craving vary in different phases of the menstrual cycle, being the greatest in the late luteal phase and during menses.8 Selection of quit dates and coping skills taught should take into account the influence of the menstrual cycle on cigarette craving and negative affect.
Health Effects of Cigarette Smoking REPRODUCTIVE OUTCOMES Several studies have reported reduced fertility and increased menVolume 7, Number 2, 2000
strual problems in women who smoke. Smoking causes women to enter menopause 1 to 2 years early.9 Alterations in sperm density and quality have been noted among males as well.9 The effects on the fetus of maternal smoking have been extensively studied.1,9 Infants born to women who smoke during pregnancy weigh, on average, 200 g less than infants born to nonsmokers. The risk of having a low birth weight infant is doubled in smokers; this effect is independent of other factors known to cause low birth weight. An estimated 17–26% of low birth weight births could be prevented by eliminating smoking during pregnancy. Women who stop smoking before becoming pregnant or in the first 3– 4 months of pregnancy have infants of the same birth weight as never smokers. Even stopping smoking before the 30th week of gestation results in higher birth weight infants compared with continuing smoking.9 Preterm delivery (⬍ 37 weeks gestation) is associated with maternal smoking. An estimated 7–10% of these deliveries could be prevented by eliminating smoking during pregnancy. In addition, the risk of intrauterine growth retardation is four times higher among women who smoke during their pregnancy. Several mechanisms are thought to cause the reduction in fetal growth, including impaired maternal weight gain and increased cyanide exposure (leading to impaired vitamin B12 metabolism). However, the primary mechanism for the reduction in fetal growth is thought to be intrauterine hypoxia, which is caused by increased carboxyhemoglobin production from carbon monoxide exposure and vasoconstriction of the umbilical arteries.9 Maternal smoking is also associated with higher fetal, neonatal, and infant mortality. Some data support an association between smoking and increased risk of spontaneous
abortion. Smoking during pregnancy increases the risk of placenta previa and abruptio placentae and decreases the risk of preeclampsia.1 Maternal smoking during pregnancy is also a strong risk factor for sudden infant death syndrome (SIDS).9 Studies have consistently shown a 2- to 4-fold increased risk of SIDS among infants whose mothers smoked during pregnancy compared with infants of nonsmoking mothers, even after other risk factors were controlled for.9 Most hypotheses about possible mechanisms center around the effects of maternal smoking on fetal oxygenation and fetal development.9 Definite conclusions about the longterm consequences of maternal smoking on offspring cannot be made at this point. However, the few studies that have examined the long-term consequences of maternal smoking suggest a slight increase in the incidence of mental retardation, cerebral palsy, epilepsy, hyperactivity, shortened attention span, lowered test scores, and electroencephalographic abnormalities.9
CANCER Smoking causes lung, oral, laryngeal, and esophageal cancer.9 Most cases of these cancers, and more than 44,000 deaths (40,000 from lung cancer alone) of women each year, are attributable to smoking.10 About 30% of bladder, renal, and pancreatic cancers in women are attributable to smoking, causing more than 5,000 deaths per year. Although sexually transmitted diseases may be responsible for most cases of cervical cancer, components of tobacco smoke have been found in cervical mucus and discovered to have mutagenic activity; it is estimated that cigarette smoking causes 1,300 cervical cancer deaths each year.10 79
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CARDIOVASCULAR DISEASE Cardiovascular disease is the leading cause of death among smokers, killing more than 60,000 women each year.10 Smoking is causally associated with coronary heart disease (CHD) and stroke, particularly cerebral infarction and subarachnoid hemorrhage.9 In studies of women using high-dose oral contraceptives, increased cardiovascular risk was reported among smokers; it is unclear if this pattern holds for users of the newer, low-dose pills as well.9 Smoking is the strongest risk factor for atherosclerotic peripheral arterial occlusive disease.9
OTHER DISEASES Cigarette smoking results in more than 28,000 deaths among women each year from chronic obstructive pulmonary disease. 10 Cigarette smoking has also been linked to osteoporosis and depression; however, more research is needed before causality can be established.9
Health Effects of Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is a combination of diluted mainstream smoke exhaled by smokers and sidestream smoke from the burning end of the cigarette. ETS causes over 1,800 lung cancer deaths each year among nonsmoking women.10 CHD mortality also appears to be 23% higher among never-smokers exposed to ETS than those who were unexposed.1 ETS causes an increased risk of lower respiratory infections, such as pneumonia and bronchitis, in children; an estimated 150,000 to 300,000 cases each year among infants and children up to 18 months of age are attributable to ETS exposure.1 ETS is also causally associ80
ated with fluid in the middle ear, symptoms of upper respiratory tract irritation, reduced lung function, and additional episodes and increased severity of asthma in children. An estimated 200,000 to 1 million asthmatic children have their condition worsened by exposure to ETS, and ETS is also a risk factor for new onset of asthma among previously asymptomatic children.1 Several studies have shown an association between ETS exposure and SIDS that is independent of maternal smoking during pregnancy. This association has been found for maternal smoking, paternal smoking, and smoking by others in the household. A dose-response relationship with increasing number of smokers has also been reported.1
in identifying tobacco users and delivering effective interventions. These guidelines can be applied to cigarette, cigar, and smokeless (spit) tobacco users. An updated version of the guidelines should be released by the end of Spring 2000. The AHCPR principal findings are: ●
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Teachable Moments— The Physician’s Role Only half of women smokers who had seen a physician in the past year report that they were advised to stop smoking.11 Yet smokers cite a physician’s advice to quit as an important motivator for attempting to stop smoking.12 Research shows that tobacco use treatment interventions delivered by health care providers increase cessation rates among the general population and pregnant women.13,14 Office visits are teachable moments. Women are especially receptive to advice to quit during pregnancy, when seeking contraceptive advice, while trying to conceive, or when they have a young child in the home. An office visit provides a unique opportunity to question patients about tobacco use, explain the health risks of tobacco use and ETS, and offer cessation advice. The Agency for Health Care Research and Quality (AHRQ), formally provides strategies and recommendations to assist clinicians
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Effective treatments for tobacco use are available, and every patient who uses tobacco should be offered treatment at every office visit. Clinicians should ask and record the tobacco-use status of every patient. Even brief advice to quit is effective. The more intensive the treatment, the more effective it is in producing long-term abstinence from tobacco. Pharmacotherapy, social support from clinicians, and skills training are particularly effective components of smoking cessation treatment. Health care systems should make institutional changes that result in the systematic identification of, and intervention with, all tobacco users at every visit.13
Clinician Intervention: the 4 A’s Clinicians can intervene by following the four A’s—Ask, Advise, Assist, Arrange.13
ASK Routinely ask about and record each patient’s tobacco use status. A reliable officewide system should be established that ensures consistent documentation of the patient’s tobacco use. For example, the vital signs record can be expanded to include tobacco use and ETS status. Nurses or other staff can ask simple questions about whether the patient smokes cigarettes or cigars or uses other forms of tobacco, and whether Prim Care Update Ob/Gyns
WOMEN AND SMOKING Table 1. Components of Clinical Interventions Designed to Enhance Motivation to Quit Smoking: The “4Rs.”13 Relevance Risks
Rewards
Repetition
Motivational information has the greatest impact if it is relevant to a patient’s disease status, family or social situation, health concerns, age, and gender. Identify the potential negative consequences of smoking most relevant to the patient. Emphasize that smoking low-tar/lownicotine cigarettes or use of smokeless tobacco, cigars, and pipes will not eliminate risk: ● Acute risks: Shortness of breath, exacerbation of asthma, impotence, infertility, increased serum carbon monoxide. ● Long-term risks: Heart attacks and strokes; lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix); chronic bronchitis; and emphysema. ● Environmental risks: Increased risk of lung cancer in spouse; higher rates of smoking by children of smokers; increased risk for SIDS, asthma, middle ear disease, and respiratory infections in children of smokers. Identify the potential benefits of quitting smoking most relevant to the patient. Examples include: ● Improved health ● Food will taste better ● Improved sense of smell ● Save money ● Feel better about yourself ● Home, car, breath smell better ● Can stop worrying about quitting ● Set a good example for kids ● Have healthy babies and children ● Not worry about exposing others to smoke ● Feel better physically ● Freedom from addiction ● Perform better in sports The motivational intervention should be repeated every time a patient visits the clinic setting.
anyone smokes inside the house. An identifier can be placed on each smoker’s chart for future reference.
ADVISE Strongly advise all tobacco users to quit. Advice should be clear, strong, and memorable. Advice should also be personalized and made relevant to each patient’s history, age, and situation. For example, teens may be more motivated by the short-term benefits of quitting such as smelling better, saving money, and gaining control. Adults need to know the health risks to themselves and to those exposed to their secondhand smoke. Pregnant women respond to information on health risks to the fetus and infants. Mothers with young children respond to information on the increased risk of SIDS Volume 7, Number 2, 2000
and childhood respiratory illnesses. Some women respond to the increased risks associated with oral contraceptive use, or to the increased risk of impaired fertility or osteoporosis. Clinic and office staff can reinforce the cessation message and support the patient’s quit attempt. If the patient is unwilling to make a quit attempt, you can provide a motivational intervention. Motivational interventions are characterized by the four Rs: Relevance, Risks, Rewards, and Repetition (Table 1).
ASSIST Ask tobacco users if they are willing to make a quit attempt. Patients who are ready should be offered assistance and helped with a quit plan.
The doctor or staff can ask the patient to set a quit date, provide brief counseling, provide self-help materials that offer tips for cessation, and encourage the use of nicotine replacement therapy or bupropion. Cessation rates are increased when the counseling provides social support and problem solving skills that help tobacco users recognize and cope with problems encountered in quitting (Tables 2 and 3).13 All pregnant women, and any other smoker willing to receive more intensive interventions, particularly highly addicted smokers or smokers who have made multiple quit attempts, should be strongly encouraged to call a telephone quitline, if available, or go to a smoking cessation specialist or group program. To obtain information on cessation programs in your area, call the local health department, health maintenance organizations, local hospitals, the American Cancer Society, the American Heart Association, or the American Lung Association. The Food and Drug Administration (FDA) has approved four forms of nicotine replacement therapy: a nicotine nasal spray, a nicotine inhaler, nicotine gum, and the transdermal patch. The latter two are sold over the counter. The FDA has also approved bupropion hydrochloride (ZYBAN) as a cessation aid. These therapies consistently increase cessation rates, especially when combined with behavioral counseling. The product used depends upon medical contraindications and patient preference.
ARRANGE Arrange follow-up visits, phone calls and/or letters for all patients trying to quit. Research has shown that patients are more likely to succeed in quitting if they know their progress is being monitored and if they receive continued support and encouragement. Contact should be 81
SIENER ET AL Table 2. Common Elements of Supportive Smoking Cessation Treatments13 Supportive treatment component
Examples
Encourage the patient in the quit attempt.
● Note that effective cessation treatments are now available. ● Note that half of all people who have ever smoked have now quit. ● Communicate belief in patient’s ability to quit.
Communicate caring and concern.
● Ask about how patient feels about quitting. ● Directly express concern and willingness to help. ● Be open to the patient’s expression of fears of quitting, difficulties experienced, and ambivalent feelings.
Encourage the patient to talk about the quitting process.
Ask about: ● Reasons the patient wants to quit. ● Difficulties encountered while quitting. ● Success the patient has achieved. ● Concerns or worries about quitting.
Provide basic information about smoking and successful quitting.
● The nature/timecourse of withdrawal. ● The addictive nature of smoking. ● The fact that any smoking (even a single puff) increases the likelihood of full relapse.
made soon after the quit date as the majority of relapses occur within two weeks. Further contact should be made to reinforce the patient’s efforts within a month or two after
quitting or when pharmacotherapy is being withdrawn. To help prevent relapse, each follow-up contact should acknowledge a patient’s success, review the
Table 3. Common Elements of Problem-solving/Skills Training for Tobacco-use Treatments13 Problem-solving treatment component Recognition of danger situations: Identification of events, internal states, or activities that are thought to increase the risk of smoking or relapse. Coping skills: Identification and practice of coping or problem-solving skills. Typically, these skills are intended to cope with danger situations.
Basic Information: Provision of basic information about smoking and successful quitting.
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Examples ● ● ● ●
Being around other smokers Being under time pressure Getting into an argument Experiencing cravings or negative moods ● Drinking alcohol ● Learning to anticipate and avoid danger situations ● Learning cognitive strategies that will reduce negative moods ● Accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure ● Learning cognitive and behavioral activities that distract attention from smoking cravings ● The nature/timecourse of withdrawal ● The addictive nature of smoking ● The fact that any smoking (even a single puff) increases the likelihood of full relapse
benefits of quitting, and help to resolve problems and barriers to quitting such as depression, weight gain, or prolonged withdrawal symptoms. Patients who resume smoking should be reminded that this is not a personal failure but part of the process, and that typically several attempts to quit are necessary. Encourage the patient to learn from the situation that triggered tobacco use, revisit their reasons for quitting, and try an additional intervention. Evidence suggests that treatment can be effective even in the highly addicted smokers or smokers with depression or other psychiatric comorbidity. However, unsuccessful quit attempts and relapse tend to be higher for people with these risk factors.13
Special Concerns PREGNANCY When pregnant women are asked about their smoking status, they may deny using tobacco.13 Strong motivational messages regarding the impact of smoking on the pregnant smoker, fetus, and child, should be given and intensive counseling should be offered for all pregnant women. To date, no clinical trials have assessed the benefits and risks of nicotine replacement therapy for pregnant women.15 The AHCPR guidelines suggest that “nicotine replacement should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking.”15 There are no wellcontrolled studies of Zyban in pregnant women. Glaxo Wellcome, the company that produces Zyban, suggests that pregnant smokers be encouraged to attempt cessation using educational and behavioral interventions before pharmacological Prim Care Update Ob/Gyns
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approaches are used. Postpartum relapse rates are high even if a woman maintains abstinence throughout pregnancy. Therefore messages that stress the health risks to the smoking mother and to infants and other children exposed to secondhand smoke should be given early and reinforced through the pregnancy and after delivery. The Robert Wood Johnson Foundation has funded the project “Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy” to identify promising new approaches for pregnant smokers and new mothers.
What Physicians Can Do ●
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WEIGHT GAIN Patients should be told that some weight gain after quitting is common (most gain fewer than 10 pounds) and that strict dietary restrictions should be avoided while attempting to quit. Ex-smokers should wait until they are confident they will not return to smoking before seriously trying to reduce weight. Suggestions for moderate exercise and dietary tips can be helpful. Nonpregnant smokers greatly concerned about weight gain can use nicotine gum or Zyban, which can delay any weight gain until the patient has successfully quit. Postcessation weight gain appears to be caused both by increased intake (e.g., eating, alcohol) and by metabolic adjustments. The latter suggests that even if smokers do not increase their caloric intake, they will still gain some weight. African Americans, people under age 55, and heavy smokers are at greater risk for larger weight gain. Remind patients that weight gain is a negligible health threat compared with the risks of continued tobacco use and that quitting smoking should be the patient’s primary, immediate priority. Volume 7, Number 2, 2000
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You have the power to help patients understand the health consequences of tobacco use and to motivate them to quit. By not using tobacco, you and the staff set a good example for patients, family, and friends. You can establish a smoke-free environment as the norm. Create an environment with the right cues by placing no-smoking signs in the waiting area and displaying smoking cessation literature. Consider eliminating any magazines with smoking advertisements. When multiple staff participate in the treatment at some level, the cessation message is reinforced. Physicians and medical organizations can be a voice in the community, lending credibility to public health efforts to increase the number of smoke-free environments, restrict tobacco ads and promotions, decrease illegal sales to minors, and increase tobacco excise taxes. You can reinforce public health messages, write letters to elected officials or to the newspaper editorial pages, be spokespersons on radio or TV talk shows, and provide expert testimony on the health effects of tobacco use. You can encourage health care delivery systems to systematically provide tobacco use treatment, and to reimburse clinicians and patients for counseling and pharmacotherapy.15
You can establish an office cessation intervention that is as routine as taking weight, temperature, and blood pressure. Numerous studies have unequivocally established that smoking and secondhand smoke lead to adverse health effects. Tobacco use treatment interventions offer obstetricians and gynecologists a great opportunity to improve birth outcomes and positively im-
pact the overall health of women and their children.
Additional Information ●
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The Agency for Health Care and Quality Research (AHRQ) offers the AHRQ “Smoking Cessation: Clinical Practice Guideline” at no charge. An updated version of the guidelines should be available by the end of Spring 2000. In addition, three quick reference guides are available: “Smoking Cessation: Information for Specialists”; “Smoking Cessation: Helping Smokers Quit, A Guide for Primary Care Clinicians”; and “Smoking Cessation: A Systems Approach, A Guide for Health Care Administrators, Insurers, Managed Care Organizations, and Purchasers.” Also available are the “You Can Quit Smoking” consumer guide pamphlets that come in eight languages (English, Spanish, and 6 Asian languages) and the Smoking Cessation Consumer Tools Kit. For materials call 800358-9295 or write to the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. The full text of guideline documents is available online through AHRQ’s web site, http:// www.ahcpr.gov/clinic/. The American College of Obstetricians and Gynecologists (ACOG) developed resources to facilitate the provision of cessation treatments. Available resources include posters, sample chart stickers, a quick reference with tips for counseling and on nicotine replacement products, and a self-help pamphlet for women who smoke. This is complemented by articles on tobacco cessation in the monthly ACOG newsletter. Call 800-673-8444 for information on ACOG’s smoking cessation campaign. To order materials, call 800-762-2264, ext. 882. The National Cancer Institute 83
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manual “How to Help Your Patients Stop Smoking” provides guidance on how to implement a cessation program, including such items as sample responses to patients’ common questions and concerns, smoking cessation tips and forms. The Quit For Good material is also available free of charge from the National Cancer Institute at 800-4-CANCER. The American Cancer Society at 800-ACS-2345 has general information on the health risks of tobacco use, and several pamphlets are available at no charge to provide to pregnant women and patients thinking about or deciding to quit. Call your local ACS office for an array of office staff/ physician and patient education materials, and for information on the ACS Making Yours A Fresh Start Family cessation program. The American Lung Association at 800-LUNGUSA offers cessation information brochures for both pregnant patients and the general population. It also offers Freedom from Smoking manuals for clinic or office setting, in addition to the Freedom from Smoking Cessation Program for the general public. The guide, a Pregnant Woman’s Guide to Quit Smoking, 5th edition, produced by Smoking Cessation or Reduction in Pregnancy Trial (SCRIPT) can be ordered from the Society for Public Health Education at 202/408-9804 or through e-mail at [email protected]. The American Academy of Family Physicians at 800-944-0000 offers the AAFP Stop Smoking Kit, an office-based cessation kit with a physician/office staff manual, chart forms, and waiting room and patient handouts. Education, Training and Research Associates at 800-321-4407 produces several multicultural and
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multilingual materials for health educators and clinicians, and pamphlets for patients. The Office on Smoking and Health at CDC offers at no charge AHRQ materials, Pathways to Freedom, a smoking cessation guide appropriate for African Americans, pamphlets for individuals trying to quit, and information on secondhand smoke. Order by phone from 770-488-5705 or online through the CDC web site, http:// www.cdc.gov/tobacco.
References 1. Fielding JE, Husten CG, Eriksen MP. Tobacco: Health effects and control. In: Wallace RB, ed. Maxcy-RosenauLast Public Health and Preventive Medicine. 14th ed. Stamford (CT): Appleton and Lange, 1998:817– 45. 2. Mathews TJ. Smoking during pregnancy, 1990 –1996. In: National Vital Statistics Reports 47(10). Hyattsville (MD): National Center for Health Statistics, 1998. 3. U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, 1994. 4. Floyd RL, Rimer BK, Giovino GA, Mullen PD, and Sullivan SE. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annu Rev Public Health 1993;14:379 – 411. 5. Pierce JP, Gilpin E. A historical analysis of tobacco marketing and uptake of smoking by youth in the United States: 1890 –1977. Health Psychol 1995;14:500 – 8. 6. U.S. Department of Health and Human Services. The health consequences of smoking: nicotine addiction. A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office on Smoking and Health, Rockville, 1988. 7. CDC. Indicators of nicotine addic-
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tion among women—United States, 1991–1992. MMWR 1995;44:102–5. Gritz ER, Nielsen IR, Brooks LA. Smoking cessation and gender: the influence of physiological, psychological, and behavioral factors. J Am Med Womens Assoc 1996;51:35– 42. U.S. Department of Health and Human Services. The health benefits of smoking cessation: A report of the Surgeon General, 1990. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta. DHHS Pub. No. (CDC)90-8416, 1990. Novotny TE, Giovino GA. Tobacco use. In: Brownson RE, Remington PL, Davis JR, eds. Chronic Disease Epidemiology and Control. 2nd ed. Washington (DC): American Public Health Association Press, 1998:117– 48. Tomar S, Husten C, Manley M. Do dentists and physicians advise tobacco users to quit? JADA 1996;127: 259 – 66. National Cancer Institute. Tobacco and the clinician: interventions for medical and dental practice. NIH Publication No. 94-3693. Natl Cancer Inst Monogr 1994;5:1–22. U.S. Department of Health and Human Services. Smoking Cessation, Clinical Practice Guideline. No. 18. AHCPR Publication 96-0692, 1996. Windsor RA, Woodby LL, Mitler TM, Hardin JM , et al. Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in Medicaid maternity care. Am J Obstet Gynecol 2000;182:68 –75. Benowitz NL. Nicotine replacement therapy during pregnancy. JAMA 1991;22:3174 –7. Epps RP, Manley MW, Grande D, Lynch B. How clinicians can affect patient smoking behavior through community involvement and clinical practice. JAMA 1996;51:43–7.
Address correspondence and reprint requests to Karen Siener, MPH, Office on Smoking and Health, CDC, 4770 Buford Hwy, NE, Mailstop K-67, Atlanta, GA 39341.
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Tobacco use remains the number one cause of preventable death among women in the United States. Of particular concern to obstetricians and gynecologists is the morbidity caused by tobacco use and by exposure to secondhand smoke among women of childbearing age, pregnant women, and their newborns. Women who smoke have lower fertility rates and are more likely to experience negative side effects from oral contraceptives. Pregnant women who smoke are more likely to suffer miscarriages and to have low birth weight and preterm babies, and infants with sudden infant death syndrome. Over one of every four women aged 18 to 44 smoke in the U.S. Unfortunately, at least 14% of women smoke during pregnancy. The good news is that research shows that tobacco treatment interventions by health care providers can increase the number of patients who successfully quit. The Agency for Health Care Policy and Research developed recommendations and guidelines to assist health care providers to integrate a tobacco treatment intervention into an office setting. It is recommended that every physician 1) ask patients about their tobacco use; 2) advise them to stop using tobacco; 3) assist patients interested in cessation efforts; and From the Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, and the Cardiovascular Health Branch, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.
Volume 7, Number 2, 2000
4) arrange appropriate follow-up. (Prim Care Update Ob/Gyns 2000; 7:77– 84. © 2000 Elsevier Science Inc. All rights reserved.)
Physicians can make a difference in their patients’s use of tobacco. However, some physicians are reluctant to treat tobacco use due to time constraints, perceived lack of effective skills, frustration with low success rates, or feeling that tobacco counseling is not a priority. This article reviews current trends in cigarette smoking among women, health effects of tobacco use, the effectiveness of brief patient counseling, and the importance of intensive treatment interventions for pregnant women. For most patients, a brief counseling session can be effective, time-efficient, and rewarding for both the physician and the patient.
Prevalence of Cigarette Smoking WOMEN Data from the 1997 National Health Interview Survey, conducted by the National Center for Health Statistics indicate that over 22 million women (22%) smoke, including 14 million women of reproductive age.1 Smoking prevalence is highest among women 25– 44 years of age (26%) and among those with 9 –11 years of education (30%). Among racial and ethnic groups, American Indian and Alaska Native women
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have the highest smoking prevalence (31%), followed by white and African American women (23– 33%). Hispanic (14%) and Asian and Pacific Islander women (12%) have the lowest smoking prevalence. In the 1990s, there has been little change in smoking prevalence.1 In terms of amount of smoking, data from the National Health Interview Survey, conducted by the National Center for Health Statistics, indicate that white women are more likely to be heavy smokers than black or Hispanic women, and highly educated women are the least likely to be heavy smokers.
PREGNANT WOMEN Based on information from birth certificates, smoking during pregnancy has declined from 18% in 1990 to 13% in 1997.2 This decline was observed for all racial and ethnic groups. American Indian, white, and Hawaiian women continue to have the highest prevalence of smoking during pregnancy. Women aged 15–19 years currently have the highest rates of smoking during pregnancy (18%), and smoking in this age group increased in both 1995, 1996 and 1997. The number of cigarettes smoked per day by pregnant women declined from 1990 to 1996. However, caution must be used in interpreting birth certificate data because pregnant women probably underreport smoking to their clinicians. Data from household surveys suggest that 22% of women smoke during pregnancy.2
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ADOLESCENT GIRLS Unfortunately, in contrast to trends among women, smoking among girls increased dramatically in the 1990s until 1998, when a decrease was observed in the Monitoring the Future Study conducted by the University of Michigan. In 1999, 33% of 12th-grade girls, 26% of 10th-grade girls, and 18% of 8th-grade girls were current smokers (defined as smoking in the last 30 days). Smoking prevalence was higher for girls than boys until the late 1980s; since then, gender differences in smoking have been small.
Other Tobacco Products Women and girls are less likely to use other tobacco products then men and boys, respectively. In 1998, data from the National Household Survey on Drug Abuse (NHSDA), conducted by the National Institute on Drug Abuse, indicate that 16% of women reported ever smoking a cigar and 2% of women had smoked a cigar in the past month. Recent estimates of past-month cigar smoking among girls are conflicting and range from 3% (in the NHSDA) to 10% (in the 1999 National Youth Tobacco Survey conducted by the Centers for Disease Control and Prevention). Smokeless tobacco use among women has remained low (⬍2%).1
Quitting Behavior WOMEN In 1997, 19.2 million women were former smokers.1 The proportion of ever-smokers who have quit increases with age and is higher for white than African American women, and for women with 16 or more years of education.1 The probabilities of attempting to quit and succeeding are comparable for women and men. Unfortunately, quitting is not easier for adoles78
cents; although many adolescent girls who are regular smokers attempt to quit, most are unsuccessful.3
PREGNANT WOMEN In 1990, 23% of pregnant women quit after learning of their pregnancy; the percentage of women who quit during pregnancy increased as level of education increased.4 Pregnant women generally quit because of concerns about adverse fetal outcomes. Unfortunately, many women appear to consider cessation during pregnancy as a temporary abstinence: up to 75% of mothers resume smoking within 6 months after delivery.4 Postpartum relapse appears to be unrelated to educational level.4
Determinants RISK FACTORS FOR INITIATION AMONG ADOLESCENTS Self-esteem, self-image, psychological health, and attitudes and beliefs about the utility of smoking are important determinants of adolescent smoking.3 Several studies of adolescents have found relationships between smoking and body image, body weight, and dieting behavior.3 For example, girls aged 12–18 years who smoke are more likely than nonsmokers to believe that smoking helps keep weight down and to be attempting weight loss.3 Smoking among adolescent girls is associated with alcohol and drug abuse, early sexual relations, poor school achievement, and dropping out of school.3 Cigarette smoking may be viewed as a method of coping with anxiety, frustration, or other psychological distress induced by lack of academic success or other environmental stressors.3 Participation in organized sports and religion are protective for ciga-
rette smoking, as they may serve as alternatives for dealing with stress.3 Smoking behavior is also influenced by parental, sibling, and peer smoking; the adolescent’s perceptions of norms and expectations for smoking; the societal acceptability of smoking; and the availability of cigarettes.3 The tobacco industry, through advertising and promotions, has had a major influence on the acceptability of smoking for girls and women. One of the first major marketing efforts directed at women began in the 1920s: the American Tobacco Company’s Lucky Strike campaign featured the slogan “Reach for a Lucky Instead of a Sweet.” The themes of smoking and slenderness and smoking and liberation have been continually used by the tobacco industry in its marketing to women. For example, the Virginia Slims brand was launched with a 100 mm “slimmer than usual” cigarette and the “You’ve Come a Long Way, Baby!” slogan in 1968. A study of smoking trends among girls and women identified two major periods of increased initiation among girls and young women: one in the mid1920s coincident with the Lucky Strike women’s marketing campaigns, and one in the late 1960s coincident with large-scale marketing of women’s brands.5 In 1995, cigarette advertising and promotional expenditures were almost $5 billion, making cigarettes one of the most heavily marketed products in the U.S.1
NICOTINE ADDICTION Many girls and women who smoke are addicted to nicotine. The pharmacologic and behavioral processes that determine nicotine addiction are similar to those that determine addiction to other drugs, such as heroin and cocaine.6 Nicotine tolerance develops such that repeated use results in diminished effects and can be accompanied by inPrim Care Update Ob/Gyns
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creased intake. Physical dependence on nicotine is characterized by a withdrawal syndrome during tobacco abstinence. Withdrawal symptoms include increased appetite; depressed mood; insomnia; inability to concentrate; irritability, frustration, or anger; anxiety; restlessness; and craving for tobacco. In 1991 and 1992 about 75% of women smokers 25 years of age and older reported feeling dependent on cigarettes, 78% reported being unable to cut down on their smoking, and 35% reported feeling sick when they tried to cut down on their smoking.7 Even light smokers reported these indicators of nicotine dependence: among women smoking five or fewer cigarettes per day, 43% felt dependent on cigarettes, 54% felt unable to cut down on their smoking, and 22% felt sick when they tried to cut down on their smoking. Women are more likely than men to smoke in states of negative affect or stress.8 In addition, a history of depression is a strong risk factor for the prevalence and severity of nicotine addiction. The greater prevalence of major depression in women than men may enhance the vulnerability of women to nicotine addiction and may lead to a poorer response to smoking cessation treatment.8 Some studies indicate that smoking rates, nicotine withdrawal symptoms, and craving vary in different phases of the menstrual cycle, being the greatest in the late luteal phase and during menses.8 Selection of quit dates and coping skills taught should take into account the influence of the menstrual cycle on cigarette craving and negative affect.
Health Effects of Cigarette Smoking REPRODUCTIVE OUTCOMES Several studies have reported reduced fertility and increased menVolume 7, Number 2, 2000
strual problems in women who smoke. Smoking causes women to enter menopause 1 to 2 years early.9 Alterations in sperm density and quality have been noted among males as well.9 The effects on the fetus of maternal smoking have been extensively studied.1,9 Infants born to women who smoke during pregnancy weigh, on average, 200 g less than infants born to nonsmokers. The risk of having a low birth weight infant is doubled in smokers; this effect is independent of other factors known to cause low birth weight. An estimated 17–26% of low birth weight births could be prevented by eliminating smoking during pregnancy. Women who stop smoking before becoming pregnant or in the first 3– 4 months of pregnancy have infants of the same birth weight as never smokers. Even stopping smoking before the 30th week of gestation results in higher birth weight infants compared with continuing smoking.9 Preterm delivery (⬍ 37 weeks gestation) is associated with maternal smoking. An estimated 7–10% of these deliveries could be prevented by eliminating smoking during pregnancy. In addition, the risk of intrauterine growth retardation is four times higher among women who smoke during their pregnancy. Several mechanisms are thought to cause the reduction in fetal growth, including impaired maternal weight gain and increased cyanide exposure (leading to impaired vitamin B12 metabolism). However, the primary mechanism for the reduction in fetal growth is thought to be intrauterine hypoxia, which is caused by increased carboxyhemoglobin production from carbon monoxide exposure and vasoconstriction of the umbilical arteries.9 Maternal smoking is also associated with higher fetal, neonatal, and infant mortality. Some data support an association between smoking and increased risk of spontaneous
abortion. Smoking during pregnancy increases the risk of placenta previa and abruptio placentae and decreases the risk of preeclampsia.1 Maternal smoking during pregnancy is also a strong risk factor for sudden infant death syndrome (SIDS).9 Studies have consistently shown a 2- to 4-fold increased risk of SIDS among infants whose mothers smoked during pregnancy compared with infants of nonsmoking mothers, even after other risk factors were controlled for.9 Most hypotheses about possible mechanisms center around the effects of maternal smoking on fetal oxygenation and fetal development.9 Definite conclusions about the longterm consequences of maternal smoking on offspring cannot be made at this point. However, the few studies that have examined the long-term consequences of maternal smoking suggest a slight increase in the incidence of mental retardation, cerebral palsy, epilepsy, hyperactivity, shortened attention span, lowered test scores, and electroencephalographic abnormalities.9
CANCER Smoking causes lung, oral, laryngeal, and esophageal cancer.9 Most cases of these cancers, and more than 44,000 deaths (40,000 from lung cancer alone) of women each year, are attributable to smoking.10 About 30% of bladder, renal, and pancreatic cancers in women are attributable to smoking, causing more than 5,000 deaths per year. Although sexually transmitted diseases may be responsible for most cases of cervical cancer, components of tobacco smoke have been found in cervical mucus and discovered to have mutagenic activity; it is estimated that cigarette smoking causes 1,300 cervical cancer deaths each year.10 79
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CARDIOVASCULAR DISEASE Cardiovascular disease is the leading cause of death among smokers, killing more than 60,000 women each year.10 Smoking is causally associated with coronary heart disease (CHD) and stroke, particularly cerebral infarction and subarachnoid hemorrhage.9 In studies of women using high-dose oral contraceptives, increased cardiovascular risk was reported among smokers; it is unclear if this pattern holds for users of the newer, low-dose pills as well.9 Smoking is the strongest risk factor for atherosclerotic peripheral arterial occlusive disease.9
OTHER DISEASES Cigarette smoking results in more than 28,000 deaths among women each year from chronic obstructive pulmonary disease. 10 Cigarette smoking has also been linked to osteoporosis and depression; however, more research is needed before causality can be established.9
Health Effects of Environmental Tobacco Smoke Environmental tobacco smoke (ETS) is a combination of diluted mainstream smoke exhaled by smokers and sidestream smoke from the burning end of the cigarette. ETS causes over 1,800 lung cancer deaths each year among nonsmoking women.10 CHD mortality also appears to be 23% higher among never-smokers exposed to ETS than those who were unexposed.1 ETS causes an increased risk of lower respiratory infections, such as pneumonia and bronchitis, in children; an estimated 150,000 to 300,000 cases each year among infants and children up to 18 months of age are attributable to ETS exposure.1 ETS is also causally associ80
ated with fluid in the middle ear, symptoms of upper respiratory tract irritation, reduced lung function, and additional episodes and increased severity of asthma in children. An estimated 200,000 to 1 million asthmatic children have their condition worsened by exposure to ETS, and ETS is also a risk factor for new onset of asthma among previously asymptomatic children.1 Several studies have shown an association between ETS exposure and SIDS that is independent of maternal smoking during pregnancy. This association has been found for maternal smoking, paternal smoking, and smoking by others in the household. A dose-response relationship with increasing number of smokers has also been reported.1
in identifying tobacco users and delivering effective interventions. These guidelines can be applied to cigarette, cigar, and smokeless (spit) tobacco users. An updated version of the guidelines should be released by the end of Spring 2000. The AHCPR principal findings are: ●
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Teachable Moments— The Physician’s Role Only half of women smokers who had seen a physician in the past year report that they were advised to stop smoking.11 Yet smokers cite a physician’s advice to quit as an important motivator for attempting to stop smoking.12 Research shows that tobacco use treatment interventions delivered by health care providers increase cessation rates among the general population and pregnant women.13,14 Office visits are teachable moments. Women are especially receptive to advice to quit during pregnancy, when seeking contraceptive advice, while trying to conceive, or when they have a young child in the home. An office visit provides a unique opportunity to question patients about tobacco use, explain the health risks of tobacco use and ETS, and offer cessation advice. The Agency for Health Care Research and Quality (AHRQ), formally provides strategies and recommendations to assist clinicians
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Effective treatments for tobacco use are available, and every patient who uses tobacco should be offered treatment at every office visit. Clinicians should ask and record the tobacco-use status of every patient. Even brief advice to quit is effective. The more intensive the treatment, the more effective it is in producing long-term abstinence from tobacco. Pharmacotherapy, social support from clinicians, and skills training are particularly effective components of smoking cessation treatment. Health care systems should make institutional changes that result in the systematic identification of, and intervention with, all tobacco users at every visit.13
Clinician Intervention: the 4 A’s Clinicians can intervene by following the four A’s—Ask, Advise, Assist, Arrange.13
ASK Routinely ask about and record each patient’s tobacco use status. A reliable officewide system should be established that ensures consistent documentation of the patient’s tobacco use. For example, the vital signs record can be expanded to include tobacco use and ETS status. Nurses or other staff can ask simple questions about whether the patient smokes cigarettes or cigars or uses other forms of tobacco, and whether Prim Care Update Ob/Gyns
WOMEN AND SMOKING Table 1. Components of Clinical Interventions Designed to Enhance Motivation to Quit Smoking: The “4Rs.”13 Relevance Risks
Rewards
Repetition
Motivational information has the greatest impact if it is relevant to a patient’s disease status, family or social situation, health concerns, age, and gender. Identify the potential negative consequences of smoking most relevant to the patient. Emphasize that smoking low-tar/lownicotine cigarettes or use of smokeless tobacco, cigars, and pipes will not eliminate risk: ● Acute risks: Shortness of breath, exacerbation of asthma, impotence, infertility, increased serum carbon monoxide. ● Long-term risks: Heart attacks and strokes; lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix); chronic bronchitis; and emphysema. ● Environmental risks: Increased risk of lung cancer in spouse; higher rates of smoking by children of smokers; increased risk for SIDS, asthma, middle ear disease, and respiratory infections in children of smokers. Identify the potential benefits of quitting smoking most relevant to the patient. Examples include: ● Improved health ● Food will taste better ● Improved sense of smell ● Save money ● Feel better about yourself ● Home, car, breath smell better ● Can stop worrying about quitting ● Set a good example for kids ● Have healthy babies and children ● Not worry about exposing others to smoke ● Feel better physically ● Freedom from addiction ● Perform better in sports The motivational intervention should be repeated every time a patient visits the clinic setting.
anyone smokes inside the house. An identifier can be placed on each smoker’s chart for future reference.
ADVISE Strongly advise all tobacco users to quit. Advice should be clear, strong, and memorable. Advice should also be personalized and made relevant to each patient’s history, age, and situation. For example, teens may be more motivated by the short-term benefits of quitting such as smelling better, saving money, and gaining control. Adults need to know the health risks to themselves and to those exposed to their secondhand smoke. Pregnant women respond to information on health risks to the fetus and infants. Mothers with young children respond to information on the increased risk of SIDS Volume 7, Number 2, 2000
and childhood respiratory illnesses. Some women respond to the increased risks associated with oral contraceptive use, or to the increased risk of impaired fertility or osteoporosis. Clinic and office staff can reinforce the cessation message and support the patient’s quit attempt. If the patient is unwilling to make a quit attempt, you can provide a motivational intervention. Motivational interventions are characterized by the four Rs: Relevance, Risks, Rewards, and Repetition (Table 1).
ASSIST Ask tobacco users if they are willing to make a quit attempt. Patients who are ready should be offered assistance and helped with a quit plan.
The doctor or staff can ask the patient to set a quit date, provide brief counseling, provide self-help materials that offer tips for cessation, and encourage the use of nicotine replacement therapy or bupropion. Cessation rates are increased when the counseling provides social support and problem solving skills that help tobacco users recognize and cope with problems encountered in quitting (Tables 2 and 3).13 All pregnant women, and any other smoker willing to receive more intensive interventions, particularly highly addicted smokers or smokers who have made multiple quit attempts, should be strongly encouraged to call a telephone quitline, if available, or go to a smoking cessation specialist or group program. To obtain information on cessation programs in your area, call the local health department, health maintenance organizations, local hospitals, the American Cancer Society, the American Heart Association, or the American Lung Association. The Food and Drug Administration (FDA) has approved four forms of nicotine replacement therapy: a nicotine nasal spray, a nicotine inhaler, nicotine gum, and the transdermal patch. The latter two are sold over the counter. The FDA has also approved bupropion hydrochloride (ZYBAN) as a cessation aid. These therapies consistently increase cessation rates, especially when combined with behavioral counseling. The product used depends upon medical contraindications and patient preference.
ARRANGE Arrange follow-up visits, phone calls and/or letters for all patients trying to quit. Research has shown that patients are more likely to succeed in quitting if they know their progress is being monitored and if they receive continued support and encouragement. Contact should be 81
SIENER ET AL Table 2. Common Elements of Supportive Smoking Cessation Treatments13 Supportive treatment component
Examples
Encourage the patient in the quit attempt.
● Note that effective cessation treatments are now available. ● Note that half of all people who have ever smoked have now quit. ● Communicate belief in patient’s ability to quit.
Communicate caring and concern.
● Ask about how patient feels about quitting. ● Directly express concern and willingness to help. ● Be open to the patient’s expression of fears of quitting, difficulties experienced, and ambivalent feelings.
Encourage the patient to talk about the quitting process.
Ask about: ● Reasons the patient wants to quit. ● Difficulties encountered while quitting. ● Success the patient has achieved. ● Concerns or worries about quitting.
Provide basic information about smoking and successful quitting.
● The nature/timecourse of withdrawal. ● The addictive nature of smoking. ● The fact that any smoking (even a single puff) increases the likelihood of full relapse.
made soon after the quit date as the majority of relapses occur within two weeks. Further contact should be made to reinforce the patient’s efforts within a month or two after
quitting or when pharmacotherapy is being withdrawn. To help prevent relapse, each follow-up contact should acknowledge a patient’s success, review the
Table 3. Common Elements of Problem-solving/Skills Training for Tobacco-use Treatments13 Problem-solving treatment component Recognition of danger situations: Identification of events, internal states, or activities that are thought to increase the risk of smoking or relapse. Coping skills: Identification and practice of coping or problem-solving skills. Typically, these skills are intended to cope with danger situations.
Basic Information: Provision of basic information about smoking and successful quitting.
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Examples ● ● ● ●
Being around other smokers Being under time pressure Getting into an argument Experiencing cravings or negative moods ● Drinking alcohol ● Learning to anticipate and avoid danger situations ● Learning cognitive strategies that will reduce negative moods ● Accomplishing lifestyle changes that reduce stress, improve quality of life, or produce pleasure ● Learning cognitive and behavioral activities that distract attention from smoking cravings ● The nature/timecourse of withdrawal ● The addictive nature of smoking ● The fact that any smoking (even a single puff) increases the likelihood of full relapse
benefits of quitting, and help to resolve problems and barriers to quitting such as depression, weight gain, or prolonged withdrawal symptoms. Patients who resume smoking should be reminded that this is not a personal failure but part of the process, and that typically several attempts to quit are necessary. Encourage the patient to learn from the situation that triggered tobacco use, revisit their reasons for quitting, and try an additional intervention. Evidence suggests that treatment can be effective even in the highly addicted smokers or smokers with depression or other psychiatric comorbidity. However, unsuccessful quit attempts and relapse tend to be higher for people with these risk factors.13
Special Concerns PREGNANCY When pregnant women are asked about their smoking status, they may deny using tobacco.13 Strong motivational messages regarding the impact of smoking on the pregnant smoker, fetus, and child, should be given and intensive counseling should be offered for all pregnant women. To date, no clinical trials have assessed the benefits and risks of nicotine replacement therapy for pregnant women.15 The AHCPR guidelines suggest that “nicotine replacement should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking.”15 There are no wellcontrolled studies of Zyban in pregnant women. Glaxo Wellcome, the company that produces Zyban, suggests that pregnant smokers be encouraged to attempt cessation using educational and behavioral interventions before pharmacological Prim Care Update Ob/Gyns
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approaches are used. Postpartum relapse rates are high even if a woman maintains abstinence throughout pregnancy. Therefore messages that stress the health risks to the smoking mother and to infants and other children exposed to secondhand smoke should be given early and reinforced through the pregnancy and after delivery. The Robert Wood Johnson Foundation has funded the project “Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy” to identify promising new approaches for pregnant smokers and new mothers.
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WEIGHT GAIN Patients should be told that some weight gain after quitting is common (most gain fewer than 10 pounds) and that strict dietary restrictions should be avoided while attempting to quit. Ex-smokers should wait until they are confident they will not return to smoking before seriously trying to reduce weight. Suggestions for moderate exercise and dietary tips can be helpful. Nonpregnant smokers greatly concerned about weight gain can use nicotine gum or Zyban, which can delay any weight gain until the patient has successfully quit. Postcessation weight gain appears to be caused both by increased intake (e.g., eating, alcohol) and by metabolic adjustments. The latter suggests that even if smokers do not increase their caloric intake, they will still gain some weight. African Americans, people under age 55, and heavy smokers are at greater risk for larger weight gain. Remind patients that weight gain is a negligible health threat compared with the risks of continued tobacco use and that quitting smoking should be the patient’s primary, immediate priority. Volume 7, Number 2, 2000
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You have the power to help patients understand the health consequences of tobacco use and to motivate them to quit. By not using tobacco, you and the staff set a good example for patients, family, and friends. You can establish a smoke-free environment as the norm. Create an environment with the right cues by placing no-smoking signs in the waiting area and displaying smoking cessation literature. Consider eliminating any magazines with smoking advertisements. When multiple staff participate in the treatment at some level, the cessation message is reinforced. Physicians and medical organizations can be a voice in the community, lending credibility to public health efforts to increase the number of smoke-free environments, restrict tobacco ads and promotions, decrease illegal sales to minors, and increase tobacco excise taxes. You can reinforce public health messages, write letters to elected officials or to the newspaper editorial pages, be spokespersons on radio or TV talk shows, and provide expert testimony on the health effects of tobacco use. You can encourage health care delivery systems to systematically provide tobacco use treatment, and to reimburse clinicians and patients for counseling and pharmacotherapy.15
You can establish an office cessation intervention that is as routine as taking weight, temperature, and blood pressure. Numerous studies have unequivocally established that smoking and secondhand smoke lead to adverse health effects. Tobacco use treatment interventions offer obstetricians and gynecologists a great opportunity to improve birth outcomes and positively im-
pact the overall health of women and their children.
Additional Information ●
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The Agency for Health Care and Quality Research (AHRQ) offers the AHRQ “Smoking Cessation: Clinical Practice Guideline” at no charge. An updated version of the guidelines should be available by the end of Spring 2000. In addition, three quick reference guides are available: “Smoking Cessation: Information for Specialists”; “Smoking Cessation: Helping Smokers Quit, A Guide for Primary Care Clinicians”; and “Smoking Cessation: A Systems Approach, A Guide for Health Care Administrators, Insurers, Managed Care Organizations, and Purchasers.” Also available are the “You Can Quit Smoking” consumer guide pamphlets that come in eight languages (English, Spanish, and 6 Asian languages) and the Smoking Cessation Consumer Tools Kit. For materials call 800358-9295 or write to the AHRQ Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. The full text of guideline documents is available online through AHRQ’s web site, http:// www.ahcpr.gov/clinic/. The American College of Obstetricians and Gynecologists (ACOG) developed resources to facilitate the provision of cessation treatments. Available resources include posters, sample chart stickers, a quick reference with tips for counseling and on nicotine replacement products, and a self-help pamphlet for women who smoke. This is complemented by articles on tobacco cessation in the monthly ACOG newsletter. Call 800-673-8444 for information on ACOG’s smoking cessation campaign. To order materials, call 800-762-2264, ext. 882. The National Cancer Institute 83
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manual “How to Help Your Patients Stop Smoking” provides guidance on how to implement a cessation program, including such items as sample responses to patients’ common questions and concerns, smoking cessation tips and forms. The Quit For Good material is also available free of charge from the National Cancer Institute at 800-4-CANCER. The American Cancer Society at 800-ACS-2345 has general information on the health risks of tobacco use, and several pamphlets are available at no charge to provide to pregnant women and patients thinking about or deciding to quit. Call your local ACS office for an array of office staff/ physician and patient education materials, and for information on the ACS Making Yours A Fresh Start Family cessation program. The American Lung Association at 800-LUNGUSA offers cessation information brochures for both pregnant patients and the general population. It also offers Freedom from Smoking manuals for clinic or office setting, in addition to the Freedom from Smoking Cessation Program for the general public. The guide, a Pregnant Woman’s Guide to Quit Smoking, 5th edition, produced by Smoking Cessation or Reduction in Pregnancy Trial (SCRIPT) can be ordered from the Society for Public Health Education at 202/408-9804 or through e-mail at [email protected]. The American Academy of Family Physicians at 800-944-0000 offers the AAFP Stop Smoking Kit, an office-based cessation kit with a physician/office staff manual, chart forms, and waiting room and patient handouts. Education, Training and Research Associates at 800-321-4407 produces several multicultural and
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multilingual materials for health educators and clinicians, and pamphlets for patients. The Office on Smoking and Health at CDC offers at no charge AHRQ materials, Pathways to Freedom, a smoking cessation guide appropriate for African Americans, pamphlets for individuals trying to quit, and information on secondhand smoke. Order by phone from 770-488-5705 or online through the CDC web site, http:// www.cdc.gov/tobacco.
References 1. Fielding JE, Husten CG, Eriksen MP. Tobacco: Health effects and control. In: Wallace RB, ed. Maxcy-RosenauLast Public Health and Preventive Medicine. 14th ed. Stamford (CT): Appleton and Lange, 1998:817– 45. 2. Mathews TJ. Smoking during pregnancy, 1990 –1996. In: National Vital Statistics Reports 47(10). Hyattsville (MD): National Center for Health Statistics, 1998. 3. U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta, 1994. 4. Floyd RL, Rimer BK, Giovino GA, Mullen PD, and Sullivan SE. A review of smoking in pregnancy: effects on pregnancy outcomes and cessation efforts. Annu Rev Public Health 1993;14:379 – 411. 5. Pierce JP, Gilpin E. A historical analysis of tobacco marketing and uptake of smoking by youth in the United States: 1890 –1977. Health Psychol 1995;14:500 – 8. 6. U.S. Department of Health and Human Services. The health consequences of smoking: nicotine addiction. A report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office on Smoking and Health, Rockville, 1988. 7. CDC. Indicators of nicotine addic-
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tion among women—United States, 1991–1992. MMWR 1995;44:102–5. Gritz ER, Nielsen IR, Brooks LA. Smoking cessation and gender: the influence of physiological, psychological, and behavioral factors. J Am Med Womens Assoc 1996;51:35– 42. U.S. Department of Health and Human Services. The health benefits of smoking cessation: A report of the Surgeon General, 1990. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, Atlanta. DHHS Pub. No. (CDC)90-8416, 1990. Novotny TE, Giovino GA. Tobacco use. In: Brownson RE, Remington PL, Davis JR, eds. Chronic Disease Epidemiology and Control. 2nd ed. Washington (DC): American Public Health Association Press, 1998:117– 48. Tomar S, Husten C, Manley M. Do dentists and physicians advise tobacco users to quit? JADA 1996;127: 259 – 66. National Cancer Institute. Tobacco and the clinician: interventions for medical and dental practice. NIH Publication No. 94-3693. Natl Cancer Inst Monogr 1994;5:1–22. U.S. Department of Health and Human Services. Smoking Cessation, Clinical Practice Guideline. No. 18. AHCPR Publication 96-0692, 1996. Windsor RA, Woodby LL, Mitler TM, Hardin JM , et al. Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in Medicaid maternity care. Am J Obstet Gynecol 2000;182:68 –75. Benowitz NL. Nicotine replacement therapy during pregnancy. JAMA 1991;22:3174 –7. Epps RP, Manley MW, Grande D, Lynch B. How clinicians can affect patient smoking behavior through community involvement and clinical practice. JAMA 1996;51:43–7.
Address correspondence and reprint requests to Karen Siener, MPH, Office on Smoking and Health, CDC, 4770 Buford Hwy, NE, Mailstop K-67, Atlanta, GA 39341.
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