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Health care providers are sometimes challenged as to how to best guide pregnant women and girls who want to quit smoking. Here are responses to common issues providers face.
- Pregnancy is a stressful time - the anxiety of stopping smoking may affect the fetus and the mother’s ability to care for her child after birth.
- If I talk to my patient about quitting, it may harm my relationship with her.
- My patients who smoke are not interested in quitting.
- I’m not certain if I can be reimbursed for the time spent in addressing my patients’ smoking behaviour.
- I don’t have the time to engage them about their smoking.
- Smoking cessation programs are largely unsuccessful among pregnant girls and women, so why bother?
- I haven’t had any formal training in tobacco dependence treatment or smoking cessation.
- Can I use nicotine replacement therapy to support my pregnant patient who smokes?
- Where can I find self-help or educational material to support my patients in their effort to quit?
1. Pregnancy is a stressful time - the anxiety of stopping smoking may affect the fetus and the mother’s ability to care for her child after birth.
Response
Pregnancy can increase women’s stress level, particularly for low-income and disadvantaged girls and women. However, there is no evidence to suggest that quitting smoking during pregnancy increases stress or negatively impacts the health of the woman or the fetus. On the contrary, there is a wealth of evidence to suggest that stopping, reducing, or quitting smoking has great health benefits for mother and baby.
Further reading
2. If I talk to my patient about quitting, it may harm my relationship with her.
Response
Tobacco addiction is both an addiction and a cause of many serious illnesses – and as such, health care providers need to take an active role in assisting patients with quitting. Smoking is treatable. A non-judgmental and caring approach will help your patient feel comfortable and willing to address the issue.
Further reading
- U.S. Department of Health and Human Services, 1988. The Health Consequences of Smoking: Nicotine Addiction. A report of the Surgeon General. (No. DHHS Publication No (CDC) 88-8406). Public Health Service, Centers for Disease Control, Office of Smoking and Health, Rockville, Maryland
- Rollnick, S., W. Miller, R., et al. (2008). Motivational Interviewing in Health Care. New York, Guilford Press.
3. My patients who smoke are not interested in quitting.
Response
We know that tobacco helps to relieve stress and people find smoking beneficial in other ways. It is important not to deny these perceived benefits but to support women to examine and weigh the benefits and costs of smoking.
Often what seems to be lack of interest is actually a lack of confidence and hope they can change - so it is important to raise the issue in an encouraging way.
In fact, close to half of pregnant women who smoke either seriously consider or take steps towards stopping during pregnancy.
For patients who find it hard to conceive of giving up tobacco, it may be helpful to suggest stopping during pregnancy or cutting down, as opposed to quitting altogether. Cutting down to fewer than 10 cigarettes per day may be a practical alternative for women who are not able to quit altogether. The Start Thinking About Reducing Secondhand Smoke (STARSS) program, which focuses on supporting mothers in tobacco reduction efforts, found that when women attempt to reduce smoking, they often quit smoking or become more confident and interested in quitting smoking.
Further reading
- Crittenden, K.S., Manfredi, C., Lacey, L., Warnecke, R., Parsons, J., 1994. Measuring readiness and motivation to quit smoking among women in public health clinics. Addictive Behaviors 19, 497-507
- Mullen, P.D., 2004. How can more smoking suspension during pregnancy become life long abstinence? Lessons learned about predictors, interventions, and gaps in our accumulated knowledge. Nicotine & Tobacco Research 6, S217-S238.
- Action on Women’s Addictions, Research and Education (AWARE). June 2007. National Rollout of STARSS (Start Thinking About Reducing Secondhand Smoke) Final Report.
4. I’m not certain if I can be reimbursed for the time spent in addressing my patients’ smoking behaviour.
Response
Reimbursement for counseling and pharmacotherapy in engaging pregnant women who smoke in smoking cessation is related to greater smoking cessation during and after pregnancy. However, many jurisdictions still do not reimburse for counseling and pharmacotherapy for engaging pregnant women in tobacco dependence treatment. If such reimbursement systems do not exist, you may consider advocating for such.
Further reading
- Petersen, R., Garrett, J.M., Melvin, C.L., Hartmann, K.E., 2006. Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation. Tobacco Control 15, 30-34
5. I don’t have the time to engage them about their smoking.
Response
Evidence-based recommendations for engaging smokers are designed to be implemented in as little as 5 to 10 minutes. Having all the necessary tools to engage your patients – Asking, Assessing, Advising, Assisting, and Arranging – can greatly enhance your efficiency in delivering appropriate intervention. Smoking is a leading cause of illness and disease and as such is a critical part of health care support.
Further reading
1. Fiore, M., et al Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services. Public Health Service. , Rockville, MD.
6. Smoking cessation programs are largely unsuccessful among pregnant girls and women, so why bother?
Response
Up to one out of five pregnant women who smoke is able to quit by the time she delivers. Despite the relatively low success rate it is important to consider the clinical significance on maternal and fetal outcomes.
Further Reading
- Li, C.Q.,et al., 1993. The impact on infant birth weight and gestational age of cotinine-validated smoking reduction during pregnancy. JAMA 269, 1519-1524
- England, L.J., Kendrick, J.S., Wilson, H.G., Merritt, R.K., Gargiullo, P.M., Zahniser, S.C., 2001. Effects of smoking reduction during pregnancy on the birth weight of term infants. American Journal of Epidemiology 154, 694-701.
- Secker-Walker, R.H.,et al 1998. Estimated gains in birth weight associated with reductions in smoking during pregnancy. J Reprod Med 43, 967-974.
7. I haven’t had any formal training in tobacco dependence treatment or smoking cessation.
Response
There are several ways to receive training on tobacco dependence treatment and smoking cessation. The following links provide information on training, online learning modules, and resources to better equip you in engaging with pregnant women about smoking.
Further Reading
8. Can I use nicotine replacement therapy to support my pregnant patient who smokes?
Response
There are no evidence-based guidelines for the use of nicotine replacement therapy for tobacco dependence treatment in pregnancy. Using nicotine as an aid to stop smoking during pregnancy may be more beneficial than continued smoking, even though nicotine is known to be teratogenic (relating to, or causing malformations of an embryo or fetus).
Patients must be informed of the risks and, in addition, should be encouraged to use non-pharmaceutical methods to try to quit. However, for patient who are highly dependent and who cannot quit with behavioural approaches alone, nicotine replacement therapy may be recommended. Recent studies have demonstrated that nicotine replacement therapy combined with behavioural counseling can triple the chances of successful quitting during pregnancy.
Further readings
- Benowitz, N., Dempsey, D., 2004. Pharmacotherapy for smoking cessation during pregnancy. Nicotine & Tobacco Research: Official Journal Of The Society For Research On Nicotine And Tobacco 6 Suppl 2, S189-202
- Pollak, K.I.,et al., 2007. Nicotine Replacement and Behavioral Therapy for Smoking Cessation in Pregnancy. American Journal of Preventive Medicine 33, 297-305.
9. Where can I find self-help or educational material to support my patients in their effort to quit?
Note also that Quitlines may be a good place to begin referring your patients. They have links to the most up-to date provincial print resources available as well as telephone support. A list of quitlines by province can be found at on the Health Canada webpage.
See the resources section »
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