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Smoking cessation in pregnancy.

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VOL: 101, ISSUE: 06, PAGE NO: 50

Jennifer Percival, RN, RM, RHV, FETC, is tobacco education project manager, Royal College of Nursing, London

The problems associated with smoking in pregnancy have been highlighted by Poswillo and Alberman (1992):

The problems associated with smoking in pregnancy have been highlighted by Poswillo and Alberman (1992):

- Ectopic pregnancy;

- Vomiting and generally feeling unwell;

- Vaginal bleeding and the possibility of miscarriage;

- Early rupture of the amniotic membranes;

- Premature birth;

- Low birth-weight baby, with increased risks to the child's health;

- Death of the baby just before or just after the birth;

- Increased risk of sudden infant death syndrome (SIDS or 'cot death').

Many women believe that the damage caused by smoking occurs in the first three months of pregnancy (Owen and Penn, 1999), whereas the adverse effects occur mainly in the second and third trimesters.

Cigarette smoke contains carbon monoxide that bonds readily with haemoglobin, reducing the amount of oxygen in circulation. This results in the smoker having a weaker, and less developed, baby. On average, a smoker's baby weighs 250g less at birth than that of a non-smoker (Larsen et al, 2002).

National smoking cessation guidelines
These state: 'Pregnant smokers should be given firm and clear advice to stop smoking opportunistically throughout pregnancy and given as much support as possible' (West et al, 2000).

Evidence shows that the earlier the mother stops smoking, the greater the benefits she and her baby will enjoy. Helping pregnant smokers to stop is 3-6 times as cost-effective as treating smoking-related problems in newborn infants (Buck et al, 1997).

Despite this evidence, many professionals have concerns about discussing smoking with pregnant women and feel that their knowledge and skills relating to smoking cessation are inadequate (Owen and Penn, 1999).

Conversations between a pregnant woman and a midwife about smoking often take place during the booking clinic in the early stages of pregnancy. However, during the discussions, assumptions may be made about why the woman chooses to smoke, and I have found that midwives often have a poor understanding of nicotine addiction.

Helping women to give up smoking
Although many pregnant women are highly motivated to give up smoking, others may decide not to, in which case their choice must be respected. Many women are caught between trying to do the best for their baby and their need to continue smoking. It is important to provide clear information about the risks of continuing to smoke and the benefits of giving up, and help the women to voice their concerns. They should be informed about services that are available and, where appropriate, referred to the smoking cessation service.

Strategies to help women give up smoking - A number of simple approaches can be used to help women consider giving up smoking. The questions below are a means of helping you to find out more about the woman's concerns and attitudes. It is always important to make the advice personal.

- Try asking 'How many packets a day do you smoke?' instead of the number of cigarettes she smokes. The response is likely to be more accurate.

- If a woman indicates she has reduced her consumption during pregnancy, ask 'Why did you decide to cut down?' This initiates a conversation about the individual's concerns about continuing smoking. Never encourage cutting down: smokers will compensate by smoking harder and inhaling more deeply on the cigarettes they continue to smoke.

- Ask 'What have you heard about the effects smoking has on the foetus?' This allows you to build on the information the woman already possesses.

- If a patient describes the benefits of cessation as being 'a small baby', try asking 'Do you know how smoking makes babies smaller?' This can be followed by an explanation of the effects of smoking.

Research suggests that pregnant smokers respond to firm advice that they should stop smoking, and the national guidelines recommend this approach (West et al, 2000).

When a woman has decided to stop smoking she needs to set a stop date, identify people to support her, and consider using nicotine replacement therapy (NRT). She needs to plan ways to cope with triggers or stressful situations that cause her to smoke.

Some hospitals now have specialist advisers (Box 1) or referrals can be made to the local NHS services for smokers (Box 2).

Nicotine replacement therapy in pregnancy
NRT is used to treat addiction to nicotine and approximately doubles a person's chance of giving up smoking (Owen and Penn, 1999). During pregnancy it is important the woman considers the risks of continuing to smoke and the benefits of taking a short course of NRT: taking nicotine through a cigarette causes foetal exposure to much higher levels of nicotine, carbon monoxide and other toxins.

The National Institute for Clinical Excellence (NICE) recommends that women who are pregnant or breastfeeding should use NRT only after careful consideration of the risks and benefits and after discussion with a health professional (NICE, 2002). Health professionals can recommend NRT to aid smoking cessation to a pregnant smoker who has been unable to give up by herself in conjunction with behavioural support. Ideally, treatment should start as early as possible in the pregnancy (Benowitz and Dempsey, 2004).

Smoking after delivery
Following a woman's delivery it is important to address the subject of protecting children from exposure to second-hand smoke in the home. A 'partnership' approach works well. Start by simply acknowledging and accepting that your client smokes. If you try to show you understand that she is not ready to stop, she will be far more likely to be able to discuss ways she can minimise exposure of her child to smoke. The aim is to have a discussion to explore ways she can protect her children from exposure to tobacco smoke.

The types of questions you could ask include:

- What have you heard about smoking near children?

- Have you thought how you might keep smoke away from your baby?

- Can you make any changes to keep your baby safer?

- What about your family and friends who smoke? Could you ask them not to smoke in your home or near your baby?

- What about you or other people smoking in the car or when you go out?

- What could you do to separate children from smoke?

The point of this discussion is to get the smoker to decide and state the changes she could make, and for you to endorse them. Ideally, you want to encourage your patients to go outside to smoke whenever possible. If they are smoking indoors, encourage them to keep smoking in one place, well away from children and to ventilate the room thoroughly.

Although many women will continue to smoke in pregnancy despite all the support and help offered, you may have been able to plant a seed that starts the process of change. Even if a woman is unable to give up smoking, your work may result in her giving up during her next pregnancy.

Pam Hancock: Sheffield Stop-Smoking Service, 4 Dragoon Court, Hillsborough Barracks, Penistone Road, Sheffield, S6 2GZ.

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