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Factors Influencing the Use of Pharmacotherapy for Smoking Cessation During and After Pregnancy

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Factors Influencing the Use of Pharmacotherapy for Smoking Cessation During and After Pregnancy Factors influencing the use of pharmacotherapy for smoking cessation during and after pregnancy Mei Lin Lee BPharm (Hons), MSc (Pharm) A thesis in fulfillment of the requirements for the degree of Doctor of Philosophy Centre for Big Data Research in Health School of Public Health and Community Medicine Faculty of Medicine University of New South Wales March 2020 Thesis / Dissertation sheet Surname/Family Name : Lee Given Name/s : Mei Lin Abbreviation for degree as give in the University calendar : PhD Faculty : Medicine School : Public Health and Community medicine Factors influencing the use of pharmacotherapy Thesis Title : for smoking cessation during and after pregnancy Abstract 350 words maximum Maternal smoking cessation is key to improving maternal, neonatal and infant health. As pharmacotherapies for smoking cessation, which include nicotine replacement therapy (NRT), bupropion and varenicline, are the most effective cessation interventions in the general population, their use holds promise to promote quitting during and after pregnancy. This thesis aimed to identify factors, from the perspective of healthcare providers from healthcare providers’ perspectives, that influence the prescribing and/or use of smoking cessation pharmacotherapies among women who smoke during pregnancy and after giving birth. A study based on calls to a teratology information service found that healthcare providers have more safety concerns regarding bupropion and varenicline than other medications of same pregnancy risk category. Perceived safety concerns might limit their prescribing. A survey of Australian obstetricians and gynaecologists found that facility-level factors, including having a smoking cessation protocol and practising in remote and regional areas, were associated with familiarity with NRT patches. Among obstetricians familiar with NRT patches, those who believed that they could benefit their patients, and those who had self-efficacy to prescribe were more likely to intend to prescribe NRT patches. Although lack of knowledge of NRT patches might limit prescribing, individual beliefs might also limit the prescribing among those who were familiar with NRT. A study based on linked data comprising perinatal, hospital admission, death and dispensing records for all women who gave birth in NSW and WA, found 8.7% (95% CI 8.17-9.10) of women smoking at the time of delivery used a smoking cessation pharmacotherapy in the next 12 months. At 6.3%% (95% CI 5.89-6.69), varenicline was the most used pharmacotherapy. Maternal suitability for pharmacotherapy was not an influential factor as few maternal morbidities worsened by smoking were associated with use of these pharmacotherapies. The impact of women experiencing poor birth outcomes related to smoking was not a factor to motivate more pharmacologically assisted quit attempts. Another population-based study using linked administrative data provided evidence of varenicline’s effectiveness among postpartum maternal smokers. This evidence can be used to guide future decisions about whether to use varenicline postpartum. Robust data are required regarding safety of these pharmacotherapies during and after pregnancy to help support healthcare providers in seizing opportunities to assist pregnant and postpartum women in quitting smoking using these pharmacotherapies. Declaration relating to disposition of project thesis/dissertation I hereby grant to the University of New South Wales or its agents a non-exclusive licence to archive and to make available (including to members of the public) my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known. I acknowledge that I retain all intellectual property rights which subsist in my thesis or dissertation, such as copyright and patent rights, subject to applicable law. I also retain the right to use all or part of my thesis or dissertation in future works (such as articles or books). …………………………………………………………… 11 Mar 2020 Signature Date The University recognises that there may be exceptional circumstances requiring restrictions on copying or conditions on use. Requests for restriction for a period of up to 2 years can be made when submitting the final copies of your thesis to the UNSW Library. Requests for a longer period of restriction may be considered in exceptional circumstances and require the approval of the Dean of Graduate Research. i Originality statement I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged. Mei Lin Lee Date: 7 March 2020 ii Inclusions of publications statement UNSW is supportive of candidates publishing their research results during their candidature as detailed in the UNSW Thesis Examination Procedure. Publications can be used in their thesis in lieu of a Chapter if: • The candidate contributed greater than 50% of the content in the publication and is the “primary author”, ie. the candidate was responsible primarily for the planning, execution and preparation of the work for publication • The candidate has approval to include the publication in their thesis in lieu of a Chapter from their supervisor and Postgraduate Coordinator. • The publication is not subject to any obligations or contractual agreements with a third party that would constrain its inclusion in the thesis Please indicate whether this thesis contains published material or not: This thesis contains no publications, either published or submitted for publication ☐ (if this box is checked, you may delete all the material on page 2) Some of the work described in this thesis has been published and it has been documented in the relevant Chapters with acknowledgement ☐ (if this box is checked, you may delete all the material on page 2) This thesis has publications (either published or submitted for publication) ☒ incorporated into it in lieu of a chapter and the details are presented below CANDIDATE’S DECLARATION I declare that: • I have complied with the UNSW Thesis Examination Procedure • where I have used a publication in lieu of a Chapter, the listed publication(s) below meet(s) the requirements to be included in the thesis. Candidate’s Name Signature Date (dd/mm/yy) MEI LIN LEE 7/03/20 iii POSTGRADUATE COORDINATOR’S DECLARATION To only be filled in where publications are used in lieu of Chapters I declare that: • the information below is accurate • where listed publication(s) have been used in lieu of Chapter(s), their use complies with the UNSW Thesis Examination Procedure • the minimum requirements for the format of the thesis have been met. PGC’s Name PGC’s Signature Date (dd/mm/yy) Assoc Prof James Wood 8/03/20 For each publication incorporated into the thesis in lieu of a Chapter, provide all of the requested details and signatures required Details of publication #1: Full title: Health-care providers’ concern regarding smoking cessation pharmacotherapies during pregnancy: Calls to a teratology information service Authors: Mei Lin Lee, Duong T. Tran, Alec Welsh, Debra Kennedy, Alys Havard Journal or book name: Drug & Alcohol Review Volume/page number: https://onlinelibrary.wiley.com/doi/full/10.1111/dar.13033 Date accepted/published: Accepted on 30 December 2019, and published in Early View section of the journal Status Published x Accepted and In In progress press (submitted) The Candidate’s Contribution to the Work MLL, AH and AW conceptualised the study. MLL cleaned and analysed the data, with the assistance of DTT. MLL interpreted the results and drafted the initial manuscript with contributions from AH and DTT. MLL, AH, DTT, AW and DK revised the manuscript. All co- authors approved the final manuscript. All co-authors were responsible for making all changes requested by the journal. Location of the work in the thesis and/or how the work is incorporated in the thesis: Chapter 2 aims to investigate whether healthcare providers are overly concerned about the safety of pharmacotherapies for smoking cessation during pregnancycompared to medications in the same and other pregnancy-risk categories. These safety concerns may result in reluctance among healthcare providers to prescribe these pharmacotherapies to pregnant women. This research addresses the aim of the thesis regarding factors influencing the prescribing of smoking cessation pharmacotherapies to pregnant women. PRIMARY SUPERVISOR’S DECLARATION I declare that: • the information above is accurate • this has been discussed with the PGC and it is agreed that this publication can be included in this thesis in lieu of a Chapter • All of the co-authors of the publication have reviewed the above information and have agreed to its veracity by signing a ‘Co-Author Authorisation’ form. Primary Supervisor’s name Primary Supervisor’s signature Date (dd/mm/yy) Dr Alys Havard 12/3/20 iv Supervisor statement I hereby declare that all co-authors of publication #1 referenced in the ‘Inclusion of Publications Statement’ agree to Mei Lin Lee submitting this publication as a chapter in her doctoral thesis. I also acknowledge that Mei Lin Lee made a substantial (>50%) intellectual contribution to the paper. Dr Alys Havard Primary Supervisor Date: 9 March 2020 v Copyright statement I hereby grant the University of New South Wales or its agents a non-exclusive licence to archive and to make available (including to members of the public) my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known.
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