Issues

Pregnant Women

All pregnant smokers should be strongly encouraged to stop smoking throughout the entire length of their pregnancy. Cutting down the amount smoked is NOT sufficient. All pregnant smokers should be offered, at the very least, a minimal intervention (See below). Whenever possible, intensive counseling is recommended. It's never too late to quit smoking during pregnancy. Health benefits, for both the mother and fetus, can be obtained throughout the entire 9 months.

The same behavioral interventions that have been shown to be effective with all smokers should be applied to the pregnant smoker. Remember the Five A's:

1. Ask every pregnant women about smoking -- some pregnant women may try to hide their smoking status or try to minimize their use.
2. Advise every pregnant women to quit early since this benefits the mother and fetus most. Quitting anytime (even late in pregnancy) will benefit both the mother and fetus.
3. Assess the willingness of the women to make a quit attempt.
4. Assist every pregnant woman by providing motivational messages, such as:
   "This is the most important gift you, as a new mother, can give to your baby. It will be important to stay quit after your baby is born. Remaining smoke-free will keep your baby healthy. I would like to help you stop smoking today".
5. Arrange for follow-up to assess progress. Congratulate successes -- remind the woman that she is truly helping herself and her baby. Incorporate relapse prevention strategies since postpartum relapse rates are high even if a women maintains abstinence during pregnancy.

To date, nicotine replacement, as a form of treatment, has not been systematically evaluated among pregnant smokers. According to the 1996 AHCPR [now Agency for Healthcare Research and Quality (AHRQ)] Smoking Cessation Clinical Practice Guideline, 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.

• 46 states and Washington DC require smoke-free indoor air to some degree or in some public places.
• All states prohibit sale and distribution of tobacco products to minors, but only 9 states restrict advertising of tobacco products.

Sleep and Nicotine Replacement

To examine the effect of nicotine replacement on sleep quality a randomized clinical trial of 34 cigarette smokers was conducted. They received either nicotine patches or placebo patches and sleep was polysomnographically monitored for 2 pre-cessation nights and 3 post-cessation nights. During placebo therapy subjects experienced increased sleep disturbance in withdrawal, while subjects with nicotine replacement during withdrawal experienced improvements in measures of sleep quality (sleep fragmentation, Stage 3 and Stage 4 sleep). (Wetter et al, 1995, Journal of Consulting & Clinical Psychology, 63, 658-67.)

Nurse-Managed Smoking Cessation Program with Hospitalized Smokers

A smoking cessation program initiated with inpatients by a nurse resulted in a biochemically confirmed smoking abstinence rate of 31% at twelve months, compared to 21% abstinence among those receiving usual care (p=.006). The intervention consisted of meeting with the nurse about 1 hr during hospitalization, a 16-minute videotape, a workbook and accompanying audiotape, and follow-up 10 min phone contacts by the nurse after hospital discharge at 48 hrs, 7, 21 and 90 days. This intervention could be implemented in most hospital settings at relatively low cost with one full time equivalent nurse managing approximately 500 patients attempting to quit per year.
(Taylor, CB, Miller, NH, Herman, S, Smith, PM, Sobel, D, Fisher, L & Debusk, RF (1996). A nurse-managed smoking cessation program for hospitalized smokers. American Journal of Public Health, 86, 1557-1560.)

Telephone Counseling Series Improves Quit Rate

In a large study (n=3030) of smokers randomly assigned to: a) self-help quit kit, b) kit plus 1 telephone counseling session, or c) kit plus up to 6 telephone counseling sessions - investigators found significantly higher abstinence rates in counseling groups than in the self-help group. 12-month abstinence rates were 5.4% for self-help, 7.5% for one phone call, and 9.9% for multiple calls. Calls were initiated by counselors and followed a structured protocol. The first session focused on individualized motivation to quit and promoting self-efficacy (50 min), while subsequent calls related to relapse prevention and averaged about 20 min each. A unique aspect was the relapse-sensitive scheduling of phone calls to coincide with more vulnerable periods of relapse. Therefore these calls were made 1, 3, 7, 14, and 30 days after the quit attempt. High accessibility and convenience of the telephone format were emphasized.
(Zhu, S-H, Stretch, V, Balabanis, M, Rosbrook, B, Sadler, G & Pierce, JP ( 1996). Telephone counseling for smoking cessation: effects of single session and multiple session interventions. Journal of Consulting and Clinical Psychology, 64, 202-211.)

Time to First Cigarette

Time to first cigarette of the day in minutes has been identified as an important predictor of the degree of nicotine dependence. This is also a consideration in developing an appropriate intervention strategy. A four category scoring scheme for time to first cigarette was the most powerful and practical categorical scoring method. The categories from high to lower dependence are: less than 5 min; 6-30 min; 31-60 min; and 61+ min. (Heatherton et al, 1989, British J of Addiction, 84, 791-9.)

Nicotine Addiction in Women

22 million U.S. women were smokers in 1993 and 75% of them reported feeling dependent on cigarettes. Of those who had tried to reduce the number of cigarettes smoked per day, most were unable to do so - even among those who smoked 6-15 cigarettes per day. This underscores the importance of measures to increase women's access to cessation interventions, including nicotine replacement therapy.

22 million U.S. women were smokers in 1993 and 75% of them reported feeling dependent on cigarettes. Of those who had tried to reduce the number of cigarettes smoked per day, most were unable to do so - even among those who smoked 6-15 cigarettes per day. This underscores the importance of measures to increase women's access to cessation interventions, including nicotine replacement therapy. (MMWR, 1995, 44:102-105)

Special Needs of Women In Smoking Cessation

Women who were less successful in quitting smoking during a multi-component cessation program in Toronto had:

• mothers who were smokers
• a history of asthma
• children
• a higher intake of chocolate and candy prior to the intervention

Addressing each of these issues in intensive smoking cessation interventions for women may increase their likelihood of success.
(Jansen, PM, Coambs, RB (1994). Health and behavioral predictors of success in an intensive smoking cessation program for women. Women & Health, 21, 57-72.)

Higher Lung Cancer Risk in Women

The odds ratios for major lung cancer types were consistently higher from women than men at every level of exposure to cigarette smoke in a large hospital-based, case-control study by the American Hospital Foundation. The gender difference could not be explained by differences in baseline exposure, smoking history, or body size, but is likely due to the higher susceptibility to tobacco carcinogens in women.

The odds ratios for major lung cancer types were consistently higher from women than men at every level of exposure to cigarette smoke in a large hospital-based, case-control study by the American Hospital Foundation. The gender difference could not be explained by differences in baseline exposure, smoking history, or body size, but is likely due to the higher susceptibility to tobacco carcinogens in women.

(Zang, EA & Wynder, EL (1996). Differences in lung cancer risk between men and women: examination of the evidence. Journal of National Cancer Institute, 88, 183-192.)

Smoking Cessation in Pregnancy Different From That in Nonpregnant Women

Over 200 women participated in a study describing stages of change and activities used to promote change. Even though pregnant women in the study were abstinent from cigarettes, they were not engaging in coping activities at levels associated with the action stage of change leading to successful smoking cessation. External factors such as nausea, baby's health, and social stigma and pressure, seemed to negate the need for extensive coping strategies during pregnancy. However, research has shown that experiential strategies in contemplation and preparation stages of change are most important in leading to a cognitive/attitudinal change. The lack of coping strategies used during pregnancy may be a partial explanation for high postpartum rates of smoking relapse. Traditional relapse prevention programs would not be sufficient in the postpartum period since women probably had not progressed through contemplation and preparation phases of smoking cessation during their pregnancy.

Over 200 women participated in a study describing stages of change and activities used to promote change. Even though pregnant women in the study were abstinent from cigarettes, they were not engaging in coping activities at levels associated with the action stage of change leading to successful smoking cessation. External factors such as nausea, baby's health, and social stigma and pressure, seemed to negate the need for extensive coping strategies during pregnancy. However, research has shown that experiential strategies in contemplation and preparation stages of change are most important in leading to a cognitive/attitudinal change. The lack of coping strategies used during pregnancy may be a partial explanation for high postpartum rates of smoking relapse. Traditional relapse prevention programs would not be sufficient in the postpartum period since women probably had not progressed through contemplation and preparation phases of smoking cessation during their pregnancy.

(Stotts, Al, DiClemente, CC, Carbonari, JP & Mullen, PD (1996). Pregnancy smoking cessation: a case of mistaken identity. Addictive Behaviors, 21, 459-471.)

Minimize Weight Gain with Moderate Physical Activity

Concern about weight gain is often a barrier to women attempting to quit smoking and this study was designed to examine whether weight gain could be modified by increased exercise. In a 2-year period, 1,474 women who stopped smoking gained 3.0 kg while 7,832 women who continued smoking gained 0.6 kg. Women who quit smoking and increased exercise by between 8 to 16 MET-hours per week gained 1.8 kg. Walking at an average pace for 1 hour is estimated to consume about 3.0 MET-hours, for example. Those who increased exercise by more than 16 MET-hours per week gained 1.3 kg. Benefits of quitting far outweigh the risks associated with typical post-cessation weight gain. In the Nurses' Health Study, total mortality rates for former smokers dropped by 17% compared to those who continued to smoke. The take-home message for clients: weight gain after smoking cessation can be minimized by even modest amounts of exercise.

Concern about weight gain is often a barrier to women attempting to quit smoking and this study was designed to examine whether weight gain could be modified by increased exercise. In a 2-year period, 1,474 women who stopped smoking gained 3.0 kg while 7,832 women who continued smoking gained 0.6 kg. Women who quit smoking and increased exercise by between 8 to 16 MET-hours per week gained 1.8 kg. Walking at an average pace for 1 hour is estimated to consume about 3.0 MET-hours, for example. Those who increased exercise by more than 16 MET-hours per week gained 1.3 kg. Benefits of quitting far outweigh the risks associated with typical post-cessation weight gain. In the Nurses' Health Study, total mortality rates for former smokers dropped by 17% compared to those who continued to smoke. The take-home message for clients: weight gain after smoking cessation can be minimized by even modest amounts of exercise.

(Kawachi, I, Troisi, RJ, Rotnitzky, AG, Coakley, EH, & Colditz, GA. (1996). Can physical activity minimize weight gain in women after smoking cessation? American Journal of Public Health, 86, 999-1004.)

Carbon Monoxide in Exhaled Breath

Carbon monoxide (CO) is a noninvasive measure to verify smoking status and provide educational information to the person who smokes. CO is a product of combustion and is therefore related to the time since the last cigarette was smoked. It is most effective if measured within 4 hrs of a cigarette. It can be used to compare changes over time.

The Bedfont Mini Smokerlyzer and Micro Smokerlyzer are two types of instruments that are portable, accurate, and reliable. They trap an end-tidal breath sample on the sensor surface which is converted to an electrical signal and displayed in parts per million. A visual graph on the front of the instrument shows the correlation of lung CO with carboxyhemoglobin. In addition, patients report that an audible beep accompanying the visual graph is a helpful motivator.

One source for purchase of the equipment is:

Innovative Medical Marketing Associates
520 Stokes Road
Ironstone Building B-2
Medford, NJ 08055
609-654-5561
1-800-457-5804
Fax: 609-654-2443

Cost is approximately $1650.

Disposable mouthpieces and calibration kits are also available from this source.

Accutest Nicometer

Tests for cotinine, a nicotine metabolite, in urine or saliva.  Single use tests take 15 minutes to complete and indicate either the presence or absence of exposure to nicotine.  Nicotine exposure can be through cigarettes, cigars, smokeless tobacco, or nicotine replacement therapy.  Can be used to assess smoking cessation compliance, if there is no nicotine replacement being used, or to verify tobacco use claims.  cost: $4.00 per unit, sold in 100 unit packages.  JANT Pharmacal corp. 1-800-676-5565 or www.accutest.net

NicCheck I

This is a diagnostic test strip, by DynaGen, Inc., that detects nicotine and its metabolites in urine. This product can be used to tailor replacement therapy according to consumption level, verify cessation, provide positive reinforcement of success, and can be used to motivate smokers to kick the habit. For more information on the product or to order, call 1-888-nictest (in the US) and 1-617-491-2527 (outside the US).

Teaching Video

Take Time to Help, American Cancer Society (1993); 28 minutes, $4.00.
Four nurses in different specialty areas intervene with patients in relation to smoking cessation. Overview of contents of cigarette, effectiveness of health professional intervening with patients and importance of follow-up. Patient examples: Nurse Practitioner in prenatal clinic- discusses effect of smoking on pregnancy, contracting quit date, and follow-up phone call plan. Occupational health nurse in industry- with client discusses relapse, weight gain, and nicotine replacement. School nurse in urban high school-peer pressure, smoke odor, and one day at a time approach discussed. Hospital staff nurse- inpatient upset about not smoking, discussed environment tobacco smoke, children's exposure, follow-up to physician, resources available. 

• Don't Smoke.com: on-line discussions, bulletin boards, "adopt-a-smoker" program, and anonymous support for smokers who are trying to quit.
• Quitnet.com: Quitting guides, calendars, peer support services, counselors, and a national directory of smoking cessation programs.  Some services require registration of your email address and other information.