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Improving Pregnancy Outcomes Through Smoking Cessation

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Improving Pregnancy Outcomes Through Smoking Cessation Improving Pregnancy Outcomes through Smoking Cessation Central Jersey Family Health Consortium Improving Pregnancy Outcomes through Smoking Cessation Aut hors Cheryl A. S. McFarland, PhD Ruth Brogden, MPH Robyn D’Oria, MA, RNC, APN Velva Dawson, MPA Acknowledgements This report was supported by Funding Opportunity Number CMS-1G1-12-001 from the US Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) under Cooperative Agreement No. 1G1CMS331386-01-07. The contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS, any of its agencies, or any agency of the State of New Jersey. We would like to recognize Margaret Koller and Michelle Pichardo for their review and recommendations throughout this process. Their insight was invaluable to this project. We would also like to acknowledge staff from the Southern New Jersey Perinatal Cooperative for their assistance with this project. Finally, we would like to thank CJFHC staff, specifically Fran LoRaso and Tom Eagan, who aided in the business processes needed to support this work and Melissa Garcia and Amira Elsayed who reviewed and provided research support for this project. Table of Contents Executive Summary i Introduction 1 Health Effects of Smoking in Pregnancy 1 Pregnancy and Second Hand Smoke 2 Smoking during the Postpartum Period 2 Smoking and the Life Course 3 The Financial Impacts of Prenatal Smoking 5 Reducing Healthcare Costs 6 Barriers to Quitting 7 Social/Partner Support 7 Environment 7 Stress 8 Financial 8 Summary 8 Smoking Prevalence: The Impact on Public Health 9 The Data 9 Maternal Characteristics 10 Health Behaviors and Access 11 Psychosocial Factors 12 Domestic Violence and Smoking 12 Adverse Birth Outcomes 13 Health Disparities 15 Health Disparities and Infant Outcomes in New Jersey 15 Racial Disparities and Infant Mortality 17 Smoking Postnatally 17 Summary and Conclusions 18 Strategies 19 Evidence-Based Programs 19 Other Programs 21 Gaps in Services 23 Recommendations 24 Prevention 24 Intervention 25 Conclusions 28 References 29 Appendix 1 32 Executive Summary Healthy New Jersey 2020’s goal is to reduce the Long-term negative health consequences of the percentage of women who smoke during pregnancy infant including allergies, asthma, Type 2 to 5.5 percent of mothers giving birth in New Jersey. Diabetes, gestational diabetes, hypertension, In order to achieve this goal, smoking cessation behavioral problems and cognitive delays. efforts in pregnant women will need to be promoted. In addition to health consequences, there are Central Jersey Family Health Consortium was significant financial consequences of smoking during contracted by the Rutgers Center for State Health pregnancy, such that babies born premature or low Policy, as a component of their State Innovation birth weight cost more than 12 times that of normal Model (SIM) design award funded by the Center for uncomplicated births. These costs can be greatly Medicare and Medicaid Innovation (CMMI), review reduced through smoking cessation programs which the literature on the impacts of smoking during can provide a cost savings of nearly $5 million dollars pregnancy, to conduct an analysis of birth records for New Jersey. and other data, summarize programs available for smoking cessation, identify gaps in services and Although the health consequences are well provide recommendations to identify opportunities documented, research suggests that social and family for improving birth outcomes. support, the environment, stress and finances are significant barriers to smoking cessation for pregnant The health impacts of smoking during pregnancy are women. well documented, with a burgeoning literature showing additional impacts of second and third hand Data regarding birth outcomes among women who smoke on birth outcomes. The impacts of smoking, smoke lend support for the relationship between second hand smoke and third hand smoke on smoking and adverse birth outcomes. Analysis was pregnancy and the postpartum period include: conducted using three datasets: Perinatal Risk Assessment, Electronic Birth Certificate and the Women of childbearing age who smoke are at Pregnancy Risk Assessment Monitoring System. greater risk of reduced fertility and adverse Results indicate that: pregnancy outcomes. Exposure to tobacco in utero is associated with Smoking has a negative impact on births in New increased risk of preterm birth, low birth weight, Jersey. placental abruption and stillbirth. Between 2009 and 2011 more than five percent Exposure to second hand smoke in utero or nearly 18,000 infants were born with tobacco increases the risk for preterm birth, neonatal exposure. intensive care unit admissions, respiratory Risk factors associated with smoking during distress syndrome and small for gestational age. pregnancy were lower education, being younger, Smoking during the postpartum period increases having an unplanned pregnancy, having a spouse the risk of sudden infant death syndrome. that was unemployed, experiencing domestic violence, having inadequate social support, being in poverty and being a minority. The percent of infants born with adverse birth outcomes was also higher among women who smoked. Smoking was associated with low birth weight, preterm birth, placenta previa, placenta abruption, lower APGAR scores and increased risk of infant mortality. Although, the findings suggest New Jersey experiences negative outcomes from smoking during pregnancy, currently only 37 percent of women report the provider assisting them with how to quit. i Significant research has been conducted to Evidence-based educational programs during determine which programs work best at increasing middle school smoking cessation. The research suggests that there Intervention includes: are six evidence-based strategies that purport Expansion of school-based youth services results: Providing training to providers regarding the 5 Brief interventions and the 5 A’s A’s Partnering with WIC to offer a smoking cessation Psychosocial interventions services site Quitlines Engaging public health professionals Medications-pharmacotherapy Expanding New Jersey smoking cessation Nicotine replacement therapy programs There are several smoking cessation programs In order to expand New Jersey smoking cessation available nationally and within New Jersey. However, programs, there is a need to provide additional funding and resources dedicated to such programs. the majority of programs do not focus on pregnant Moreover, providing funding to expand programs women. There are three programs that focus on focused on pregnant populations are needed. pregnant women: SmokeFreeMom Mom’s Quit Connection Perinatal Addiction Prevention Program The remaining programs are offered to the general public. The programs identified, with the exception of two (5 A’s and New Jersey Quitline), were not evidence-based programs; however, many of the programs integrate evidence-based components into their programs. There were several gaps identified in smoking cessation services to pregnant women including: Limited availability of programming focused on pregnant woman Program initiation being physician-based or within the medical setting Referral-based programming Lack of focus on second and third hand smoke Limited service locations In order to reduce the number of pregnant women who smoke and achieve the Healthy New Jersey 2020 goal, smoking cessation efforts in pregnant women will need to be promoted. Recommendations for achieving cessation among pregnant women include both prevention and intervention techniques. Prevention includes: Anti-smoking marketing campaigns ii Introduction Healthy New Jersey 2020 (HNJ 2020), New Jersey’s birth outcomes as a component of their State state health promotion and disease prevention Innovation Model (SIM) design award funded by the agenda, has identified five health priorities: asthma, Center for Medicare and Medicaid Innovation (CMMI). diabetes, obesity, hypertension, and tobacco use This report will focus on the topic of tobacco use, (specifically during the prenatal period). As part of the specifically: (1) understanding what the data say about focus on tobacco use, the Healthy New Jersey 2020’s smoking during pregnancy in New Jersey (2) strategies goal is to reduce the percentage of women who for decreasing tobacco use during pregnancy, (3) smoke during pregnancy to 5.5 percent of mothers integrating behavioral health services, and (4) giving birth in New Jersey. In order to achieve the goal addressing Medicaid cost/value, especially for high- smoking cessation efforts among pregnant women will cost patients. The report will also include need to be promoted. recommendations for best clinical practices to Central Jersey Family Health Consortium was increase smoking cessation during pregnancy while contracted by the Rutgers Center for State Health understanding the personal, social, and financial Policy to conduct an analysis of birth records and barriers that prevent a pregnant woman from seeking other data to identify opportunities for improving out and successfully completing treatment. Among pregnant women, tobacco use is still one of the few remaining causes of adverse birth outcomes that are completely preventable. Health Effects of Smoking in Pregnancy Smoking and Pregnancy Tobacco related mortality is the leading cause of preventable death in the U.S. People who smoke have a mortality rate three times
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