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Smoking and pregnancy: how can we help mothers?

Jennifer Percival
RGN RM RHV FETC DipCouns
Royal College of Nursing Tobacco Education Project Manager
E:jennifer.percival@usa.net

Although all women are encouraged to stop smoking before getting pregnant, in practice many continue until their pregnancy is confirmed, and 1 in 4 pregnant women continues to smoke throughout pregnancy. These women tend to be young, single, of lower educational achievement and in manual occupations. About 25% of pregnant smokers do stop for part of their pregnancy, mostly within the first trimester, but 75% of women return to smoking after the birth.(1)
A pregnant smoker is more likely to face the risks of:

  • Ectopic pregnancy.
  • Bleeding during pregnancy and miscarriage.
  • Waters breaking early and the baby being born with an infection.
  • Premature birth.
  • Low birthweight, with increased risks to the baby's health and life.
  • Her baby dying just before or just after birth.
  • Vomiting and generally feeling unwell.
  • An increased risk of sudden infant death ­syndrome (SIDS, or cot death).(2)

For women who continue to smoke throughout their pregnancy, the barriers to stopping include a perceived lack of willpower, low self-esteem and the mistaken belief that there is no benefit to the baby if they do not stop in the first three months.(1) The truth is very different, as the adverse effects of smoking in pregnancy are due mainly to smoking in the second and third trimesters.
Carbon monoxide from cigarette smoke reduces the amount of oxygen the baby receives, which results in a weaker and less developed baby. On average, a smoker's baby will weigh 250g less at birth than a nonsmoker's.(3)

The National Smoking Cessation Guidelines
The National Smoking Cessation Guidelines state that:
"Pregnant smokers should be given firm and clear advice to stop smoking opportunistically throughout pregnancy and given as much support as possible. Evidence shows that the earlier the mother stops smoking, the greater the benefits she and her baby will enjoy. Stopping smoking increases a pregnant woman's chances of having a healthy pregnancy and a well-­developed baby. Helping pregnant smokers to quit is three to six times as cost-effective as treating smoking-related problems in newborn infants."(4)
Despite this, many professionals have concerns about discussing smoking for fear of damaging their relationship with the woman or because they feel that their smoking cessation knowledge or skills are insufficient.(1)

How to help pregnant women stop smoking
Often the first time the subject will be addressed is during the booking clinic. When raising the issue it is important to provide clear information in a nonjudgemental way. Seek first to understand the situation from the woman's point of view and use every opportunity to offer sympathetic advice. Tailor your approach to the response you receive. A US review suggests that receiving social support and problem solving are the key issues for pregnant smokers.(5) Don't assume that someone else is doing this.

For women who don't want to stop

  • Explain that stopping smoking is the single best thing anyone can do for their baby. Offer to explain about the risks and the benefits of ­stopping.
  • Provide the "S is for Smoking and Pregnancy" NHS leaflet.
  • Let her know that you will be happy to talk about smoking if she has any concerns during the ­pregnancy.
  • Record the discussion in the notes.

For women thinking about stopping

  • Ask what she has heard about the health risks and the benefits of stopping.
  • Explore the reasons behind her ambivalence and find out why she is in two minds about stopping.
  • Ask whether her partner, family or friends smoke. Find out what support she would have if she decided to stop.
  • Encourage her to believe she can succeed in ­stopping if she really wants to.
  • Suggest she calls the NHS Pregnancy Smoking Helpline, 0800 169 9 169, which provides continued help and support throughout pregnancy.

Women who have decided to stop smoking

  • Help her make her plan of action. Deciding a date is important as well as identifying people to ­provide support.
  • Provide the relevant NHS leaflets.
  • Discuss using nicotine replacement therapy (NRT) if she has concerns about withdrawal symptoms.
  • Review past experience: what helped, what ­hindered?
  • Help her to plan ahead: identify future problems and work out solutions.
  • Offer your continued support and follow up on her progress or refer on to a specialist pregnancy adviser.

Following up on progress
Congratulate all women who have stopped smoking during their pregnancy. Praise and encouragement can help motivate and maintain peoples' determination. Monitoring a person's progress is an essential part of successful cessation. At the early stage people need support, so be sure they have a follow-up appointment. Research has shown that women are more likely to reduce their smoking during pregnancy if their partner joins them in doing so.

Nicotine replacement therapy in pregnancy
Nicotine replacement therapy (NRT) is a proven treatment for the addiction to nicotine and approximately doubles a person's chance of giving up smoking.(6) Although a recent article in the BMJ recommended that, to minimise potential adverse effects on the fetus, pregnant smokers should give up smoking without resorting to pharmacotherapy,(7) in practice many pregnant smokers cannot manage to stop without treatment. When prescribing NRT, it is important to take into account the risks of continuing to smoke and the benefits to pregnant smokers of using a short course of NRT. Taking nicotine through a cigarette causes fetal exposure to much higher levels of nicotine, carbon monoxide and other toxins. Even though NRT is not without some risk, it is always far safer than continued smoking. All safety concerns need to be weighed against the fact that, if the woman cannot manage to stop, the only alternative left to her is to go back to smoking cigarettes.
The National Institute for Clinical Excellence (NICE) recommends that women who are pregnant or breastfeeding be advised to use NRT only after careful consideration of the risks and benefits and after discussion with a healthcare professional.(6) Health professionals can recommend NRT to aid smoking cessation in a pregnant smoker who has been unable to quit by herself, in conjunction with behavioural support. Ideally, treatment should start as early in the pregnancy as possible.(8) To avoid unnecessary exposure of the fetus to nicotine it is probably advisable to recommend the use of intermittent delivery formulations such as the microtab, gum, lozenge and inhalator. However, if a patch is chosen because of nausea, advise it be worn for 16 hours per day only.(9)
 
Raising the issue of smoking throughout the pregnancy
Preserving a good relationship with pregnant clients is of paramount importance to most health professionals. Raising the issue of smoking during pregnancy can be hard if you are worried about getting a defensive reaction. The following dialogues show how you can work in partnership without destroying your relationship.

Smoker: I smoked throughout my last pregnancy and
    my baby was ok.
Nurse:    What sort of things have people said to you
    about smoking in pregnancy?
    It sounds as if smoking is very important to
    you.
    What have you thought about doing this time?

Smoker: I like the idea of having a small baby.
Nurse:    Why do you like that idea?
    Would you like me to explain how smoking
    makes babies smaller?
    A smaller baby sounds nice, but the truth is
    that babies born to smokers are often
    weaker and less developed.

Smoker: I have cut down and changed to a "lighter"
    brand.
Nurse:    What made you decide to do that?
    Where do you plan to go from here?
    How difficult have you found "cutting
    down"?

Smoker: I've tried to stop so many times in the past
    and it just doesn't work.
Nurse:    What made you decide to stop last time?
    Is there anything different you can do this
    time?
Many things have changed - there are now treatments to help you.
With the expert help now available and the past barriers to using NRT reduced, there has never been more help for pregnant women. Taking a partnership approach makes it easier to discuss smoking throughout pregnancy.

NHS resources
The NHS provides a range of free resources to support professionals, including leaflets, posters, baby bibs, room thermometers and cot labels. Call the NHS Helpline on 0800 169 0 169 or order on the website: www.givingupsmoking.co.uk

The NHS Pregnancy Smoking Helpline
The NHS Pregnancy Smoking Helpline - 0800 169 9 169 - is open from 12 noon to 9pm every day. This service is available for pregnant women as well as those trying to conceive and offers friendly advice to help them stop smoking. If asked, the trained counsellors can also arrange to make regular call-backs to prospective and expectant mothers, to ensure ongoing and intensive support during the quit process and after the birth of their babies.

Local NHS Stop Smoking Services
A comprehensive network of free NHS Stop Smoking Services exists across England, providing counselling and support to smokers wanting to quit. Many have specialist pregnancy advisers in post. Services are provided in group sessions or one-to-one, depending on the local circumstances and client's preferences. Most stop smoking advisers are nurses or pharmacists, and all have received training for their role. They can advise on the different medications available to help smokers quit as well as how to access these on prescription. The NHS Smoking Helpline and website can provide details of local services. Smokers can also telephone the service directly to book themselves an appointment.

Conclusion
Stopping smoking increases a pregnant woman's chances of having a healthy pregnancy and a well-developed baby. By applying the advice set out in this article you will be supporting pregnant women to consider stopping smoking and staying stopped for themselves and their baby.

References

  1. Owen L, Penn G. Smoking and ­pregnancy: a survey of knowledge, ­attitudes and behaviour, 1992-1999. London: Health Development Agency; 1999.
  2. Poswillo D, Alberman E. Effects of smoking on the fetus, neonate, and child. Oxford: OUP; 1992.
  3. Larsen LG, Clausen HV, Jonsson L. Stereologic examination of placentas from mothers who smoke during ­pregnancy. Am J Obstet Gynecol 2002;186:531-7.
  4. West R, McNeill A, Raw M. Smoking cessation guidelines for health ­professionals: an update. Thorax 2000;55:987-99.
  5. Melvin CL, Dolan-Mullen P, Windsor RA, Whiteside HP Jr, Goldenberg RL. Recommended cessation counselling for pregnant women who smoke: a review of the evidence. Tobacco Control 2000;9 Suppl 3:80-4.
  6. National Institute for Clinical Excellence. Guidance on the use of ­nicotine replacement therapy (NRT) and bupropion for smoking cessation. London: NICE; 2002.
  7. Coleman T. Special groups of ­smokers. BMJ 2004; 328:575-7.
  8. Benowitz N, Dempsey D. Pharmacotherapy for smoking ­cessation during pregnancy. Nicotine Tobacco Res 2004;6 Suppl 2:189-202.
  9. Wisborg K, Henriksen TB, Jespersen LB, Secher NJ. Nicotine patches for pregnant smokers: a randomized controlled study. Obstet Gynecol 2000;96:967-71.