Tobacco, Alcohol and Drug Use in Childbearing Families Presented by: Dona Dei, RN/MSN...

Tobacco, Alcohol and Drug Use in Childbearing

Families

Presented by:Dona Dei, RN/MSN

[email protected]

© 2007, March of Dimes

Smoking and Pregnancy


Substance Abuse During Pregnancy (SAMHSA, 2005)

Based on data collected from surveys of U.S. households in 2003 and 2004:

– 18.0 percent of pregnant women reported that they smoked cigarettes.

– 11.2 percent drank some alcohol.– 4.5 percent engaged in binge drinking.– 0.5 percent engaged in heavy drinking.– 4.6 percent used some kind of illicit

drug.


Pregnancy and Smoking

16.2 % of women smoke cigarettesSmoking is an important determinant of health status and a major contributor to prematurity, low birth weight and SIDS


Smoking Risks in Pregnancy

Ectopic pregnancyIntrauterine growth restrictionPlacenta previaAbruptio placentaePROMSpontaneous abortionPreterm delivery

SIDS (up to 4 times greater occurrence in smoking mothers)



Black smokers had substantially higher cotinine concentrations at all levels of cigarette smoking than White smokers.

Caraballo, JAMA 280:135, 1998


Smoking and Child Health


Cost of Complicated* Births


Substance Abuse During Pregnancy (SAMHSA, 2005) (Continued)

• Pregnant women are less likely to use substances than their peers.

• The exception is pregnant women aged 15 to 17; this substance use rate is 26 percent for pregnant women, compared with 19.6 percent for nonpregnant women.



Smoking during pregnancy is responsible for:– 20% of all LBW– 8% of preterm births – 5% of all perinatal deaths

Pregnant smokers compared to nonsmokers are:– 2.0-5.0 times as likely to experience PPROM– 1.2-2.0 times as likely to deliver preterm– 1.5-10 times as likely to deliver a SGA infant– 1.5-3.5 times as likely to deliver a LBW infant


Substance Abuse During Pregnancy (SAMHSA, 2005) (Continued)

• Rates of substance abuse in pregnancy have stayed constant.

• Pregnant women’s tobacco use decreased from 2002 to 2004, while alcohol and illicit drug use increased (SAMHSA, 2005).



Women more prone to substance abuse:– Earn below poverty level – Were exposed to violence as a child– Have a history of domestic abuse – Suffer depression or other mental health

problems– Have less than a high school education– Are unmarried– Are unemployed– Are involved with the criminal justice

system



• Substance use is highest in the first trimester.

• The most common form of substance use in pregnancy is smoking among White women.

• Because tobacco, alcohol and drug use in pregnancy occurs across all demographic groups, nurses should screen all women.


The Problem of Addiction

• Addiction does not occur unless psychological and social conditions promote continued drug use.

• Nurses are better able to provide support and nonjudgmental care if they respect substance users as reasonable and intelligent persons whose judgment has been impaired.


Genetic Contributions to Addiction• The propensity to specific

addictions has been linked to particular genes.

• Genetic differences may affect the seriousness of biological consequences of substance exposure in pregnancy.


Addiction as a Biopsychosocial Problem

• Addiction is produced when biological, psychological and social predispositions combine with exposure to substances and an environment that supports regular substance use.

• Nursing assessment should focus on a broad scope of personal, familial and social stressors and coping skills.


Women’s Treatment Issues

• Women may be more predisposed to addiction than men.

• Women are adversely affected by smaller amounts of alcohol and drugs than men.

• Women are more likely than men to lack resources to pay for drug treatment.


Women’s Treatment Issues (Roberts & Dunn, 2003) (Continued)

Women’s treatment programs must take a whole-life approach and address:

– Low self-esteem– The need for social services and

parenting support– Protection from violence– Training in relationship issues and

coping skills– Vocational and legal assistance


The 5 A’s

1. Ask about tobacco use2. Advise to quit3. Assess willingness to make a quit attempt

4. Assist in quit attempt5. Arrange follow-up


Ethical Challenges

• A conflict exists between the woman’s right to autonomy over her body and behavior and the nurse’s sense of obligation to prevent harm to the fetus.

• If nurses are part of an enforcement system instead of advocates for women’s needs, women may avoid prenatal care and social services.


The Nurse’s Role

• In prenatal and acute care settings, nurses should:– Thoroughly assess psychosocial risks– Conduct mutual goal-setting to

minimize harm associated with psychosocial risks

– Offer support and respect

• The sense of being valued can help drug users begin to make changes.


Tobacco Use in Pregnancy: Maternal Effects

Cigarette smoking is the most common form of substance abuse in pregnancy. It is linked to:

– Decreased fertility– Spontaneous abortion– Placenta previa– Placental abruption– Ectopic pregnancy– Preterm premature rupture of

membranes (PPROM)– Preeclampsia


Tobacco Use in Pregnancy: Fetal Effects

• Impaired transfer of oxygen and nutrition

• Long-term cognitive function and increased risk of brain damage

• Chronic low-level hypoxia• Intrauterine growth restriction (IUGR) • Preterm delivery• Low birthweight (LBW) in term infants


Tobacco Use in Pregnancy: Neonatal Effects

• Impaired respiratory function in premature infants

• Low neurobehavior scores and higher withdrawal-symptom scores

• Asthma, respiratory illness and pneumonia

• Infections of the middle ear• Increased risk of cancer and SIDS


Introducing Social Issues

The nurse should begin to explore the woman’s home situation, including:

– Stress related to work, finances, family and pregnancy

– Satisfaction with the amount and kind of support in her social network

– Feelings about self-esteem and ability to cope with stressors


Three-question Substance-use Screen

• Have you ever drunk alcohol?• How much alcohol did you drink in

the month before pregnancy?• How many cigarettes did you

smoke in the month before pregnancy?


Substance Abuse Assessment• In no case should urine or blood

testing be used without consent.• If a woman admits to substance

abuse, testing is not needed to confirm the presence of a problem.


Tobacco Use Assessment

• Women generally report their smoking status fairly accurately.

• The Fagerstrom Test for Nicotine Dependence is used to assess the level of addiction to tobacco (Heatherton et al., 1991).


The Fagerstrom Test for Nicotine Dependence• How soon after you wake up do you smoke

your first cigarette?• Do you find it difficult to refrain from

smoking in places where it is forbidden?• Which cigarette would you hate most to give

up?• How many cigarettes per day do you smoke?• Do you smoke more frequently in the first

hours after waking than during the rest of the day?

• Do you smoke if you are so ill that you are in bed most of the day?


Principles of Brief Intervention:Problem Recognition and Goal-Setting1. Provide feedback on problems, symptoms

and historical events that suggest a substance abuse problem. Offer simple, realistic information about the effects on mother and baby.

2. Advise the woman to stop (or cut down) using substances.

3. Emphasize that any action taken is the woman’s choice.

4. Give options for treatment.5. Get agreement from the woman on at least

one action to take.


Follow-up During Pregnancy and Postpartum

At each visit, the nurse should:1. Ask the woman about psychosocial

issues.– Progress in reducing substance use– Use of treatment options– Health changes

2. Impart good news.


Harm Reduction

• Harm reduction is an important principle for care of substance users (MacMaster, 2004).

• When abstinence is not achieved, reducing the harm of substance use is an important goal.


Recognizing the Full Scope of the Problem

• Few substance users are able to quit on their first attempt.

• Nurses should view any progress as worthwhile and recognize that recovery is a lifelong process.

• Women need to develop entirely new social support systems.


Smoking Treatment: Follow-up During Pregnancy

• One of the least expensive and most effective forms of follow-up is telephone contact.

• Follow-up should focus on how the effort is going; support and reinforcement for even small successes; suggestions to overcome obstacles; and health progress reports.


Smoking Treatment: Reducing Postpartum Relapse• Thirty percent to 70 percent of

smokers who quit during pregnancy relapse by 1 year postpartum (Secker-Walker et al., 1998).

• Postpartum follow-up is essential.• Nurses can offer the same tips they

gave to pregnant smokers, with emphasis on planning ahead to avoid excessive fatigue and isolation.


Summary

Nurses can:– Provide life-changing interventions for

vulnerable families– Advocate for increased funding for

women’s substance-abuse treatment– Work to reduce harmful stigma– Advocate for healthy environments that

reduce exposure to substances

Tobacco, Alcohol and Drug Use in Childbearing Families Presented by: Dona Dei, RN/MSN...

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