- While cigarette smoking has declined in the US adult population over the past decade, tobacco remains the leading preventable cause of disease and death in the U.S Tobacco Product Use Among Adults — United States, 2019 | MMWR (cdc.gov).
- Tobacco use remains a leading risk for women of childbearing age and beyond.
- In the 2019 National Health Interview Survey, 15.7% of females reported current use of tobacco products.
- Use of e-cigarettes has increased rapidly in the past few years. Use is highest among adults aged 18-24 years. Tobacco Product Use Among Adults — United States, 2019 | MMWR (cdc.gov)
- Alcohol-related mortality represents the third leading cause of preventable death for women in the U.S.
- Based on 2011-2013 data from the Behavioral Risk Factor Surveillance System, among women aged 18‐44 years asked about alcohol consumption in the past 30 days:
- 53.6% of nonpregnant women used alcohol;18.2% of reported binge drinking
- 10.2% of pregnant women used alcohol, 3.1% reported binge drinking
- Based on 2011-2013 data from the Behavioral Risk Factor Surveillance System, among women aged 18‐44 years asked about alcohol consumption in the past 30 days:
- Substance use before and during pregnancy is associated with adverse short and long-term health outcomes for women. It also increases the risks of adverse perinatal outcomes:
- Accidental over-doses are a potentially lethal consequence of prescription drug misuse.
- The risk of stillbirth is 2-3 times higher in women who use tobacco or marijuana, take prescription pain relievers, or use illegal drugs during pregnancy (See Substance Use in Women DrugFacts | National Institute on Drug Abuse (NIDA) (nih.gov).
- Cannabis use while trying to conceive may reduce the chance of conception among women with a history of pregnancy loss (Mumford et al., 2021)
- Pregnancy-related consequences from substance use can occur before the woman realizes she is pregnant.
- The preconception/ interconception period is a critical time to screen for tobacco/ alcohol/ substance use and offer intervention (See Substance Use During Pregnancy | CDC).
- Many tobacco-related complications of pregnancy (ectopic pregnancy, abnormal placentation, spontaneous abortion) occur or are determined in the earliest weeks of gestation.
- Approximately 50% of women who quit smoking during pregnancy resume smoking within 1 year postpartum, making the interconception period a critical time for screening and intervention (Tobacco and Nicotine Cessation During Pregnancy | ACOG)
- Alcohol consumption in pregnancy is the cause of fetal alcohol spectrum disorders (FASD), which are preventable if there is no fetal exposure to alcohol (See Fetal Alcohol Spectrum Disorders (FASDs) | CDC)
- NO amount of alcohol has proven safe for the embryo/fetus at any point during gestation; exposure at any time can affect brain development.
- Exposure to opioids and other substances during pregnancy can lead to neonatal abstinence syndrome, which has become a critical public health issue (Sanlorenzo et al., 2018)
- Quick and valid screening questions are available for use in a busy, primary care setting to assess tobacco, alcohol, and other drug exposures.
- The NIDA Quick Screen and full NIDA-modified ASSIST are validated for patients 18 years old or older:
- NIDA Quick Screen questions (The NIDA Quick Screen | NIDA Archives (drugabuse.gov)):
- In the past year how often have you used the following?
- 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily) [NOTE: since no amount of alcohol has been proven safe in pregnancy, women of childbearing potential should first be asked, “Do you ever drink beer, wine or mixed drinks?” before the first NIDA Quick Screen query]
- Tobacco products (never, once or twice, monthly, weekly, daily or almost daily).
- Prescription drugs for non-medical reasons (never, once or twice, monthly, weekly, daily or almost daily)
- Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily).
- In the past year how often have you used the following?
- Additional screening instruments available at www.drugabuse.gov/nmassist/
- NIDA Quick Screen questions (The NIDA Quick Screen | NIDA Archives (drugabuse.gov)):
- Evidence-based brief interventions appropriate for busy primary care practices are available to address tobacco/ excessive alcohol/ drug use. These interventions include:
- the 5A approach for women who screen positive for tobacco use (see below);
- the SBIRT approach for women who screen positive for alcohol, non-medical use of prescription drugs and illegal substances (see below)
- Additional tools available at www.drugabuse.gov/nmassist/
- The 5A Approach (Five Major Steps to Intervention (The “5 A’s”) | Agency for Healthcare Research and Quality (ahrq.gov))
- Use of the 5 A’s can take less than 3 minutes
- The model can be employed by physicians, nurses, dentists, psychologists, social workers and others:
- Ask about tobacco use:
- Identify and document tobacco use status for every patient at every visit. Consider adding this query to the routine responsibilities of the medical assistant or other personnel conducting the intake and obtaining vitals
- Advise to quit:
- In a clear, strong, and personalized manner, urge every tobacco user to quit.
- For example, “It is my recommendation for your health that you stop using all tobacco. I know this is a difficult process, but my team and I are here to help you when you are ready. Can we talk about your readiness and some strategies today?”
- If the woman desires pregnancy, the provider might state, “Quitting is one of the most important things you can do for your own health, the health of any pregnancies in your future and the health of your child(ren)”
- In a clear, strong, and personalized manner, urge every tobacco user to quit.
- Assess willingness to make a quit attempt:
- Is the tobacco user willing to make a quit attempt at this time? For example, “What would you like to do about your smoking?”
- If she is ready to quit, encourage her to set a quit date within the next 30 days
- Assist in quit attempt:
- For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit
- A primary care provider can provide this counseling themselves or refer to a specific person in the clinical setting who has been designated the office champion for smoking cessation. This person can then provide the woman with specific strategies (including local support groups, the state’s quit line, pharmacotherapy, etc.)
- For patients unwilling to quit, reinforce the health benefits and indicate you and your staff are there to provide support when she is ready. If your office has appointed an office champion for smoking cessation, the clinician could suggest a follow-up appointment to discuss personal barriers to quitting tobacco
- Arrange follow-up:
- For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date
- The provider should develop a reminder system to assure follow-up occurs at the designated time; the follow-up call can be made by the office champion or some other person in the office (advise the patient who will be calling them)
- For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit
- Ask about tobacco use:
- Secondhand smoke is linked to compromised health outcomes for fetuses, newborns, children and adults. Therefore, strategies to reduce exposures, especially if the partner smokes, should be explored for all women and especially those planning to become pregnant. Possible strategies to diminish risk are:
- No smoking in cars where woman is passenger
- Making inside the home a “no smoking” zone
- Avoiding enclosed spaces where smoking takes place such as parties, etc.
- The SBIRT Approach:
- “Screening, Brief Intervention, Referral to Treatment” (SBIRT) is designed as an early intervention for risky alcohol and drug use that a primary care provider or other qualified health care professional (e.g. registered nurse, social worker, physician assistant) can use
- The SBIRT 3-part approach is easy to learn relative to other behavioral treatment techniques. Go to SBIRT in Health Care » The BNI ART Institute | Boston University (bu.edu) to learn how to use this approach in your office
- Screening: Quickly assesses the severity of alcohol/ substance use and identifies the appropriate level of treatment (brief intervention and/or referral).
- Brief Intervention:
- Focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change
- Gives information about their substance use based on their risk assessment scores
- Advises in clear, respectful terms to decrease or abstain from substance use
- Encourages to set goals to decrease substance use and to identify specific steps to reach those goals
- Teaches behavior change skills that will reduce substance use and limit negative consequences
- Referral to Treatment:
- Provides those identified as needing more extensive treatment with access to specialty care
- The primary care practice should have established linkages to specialty addiction care to allow quick and seamless referral for women who continue risky drinking behaviors or show signs of alcohol dependence
- Healthcare professionals in areas without appropriate referral resources can still use the “screening and brief intervention” portions of the approach to help motivate patients to make healthy choices
- Encourage patients who use tobacco, excessive alcohol, or illegal substances to take advantage of the preconception period to quit for their own wellbeing and in preparation for a healthy pregnancy.
- The adverse effects of substance exposure can affect early fetal development before a woman realizes she is pregnant.
- Advise all women that no amount of alcohol has proven safe at any time in pregnancy.
- The NIDA quick screen, full NIDA-modified ASSIST, or other validated screening instrument can identify patients with risky substance exposures
- Use best practice of 5As to counsel women who use tobacco products.
- Use best practice such as SBIRT to counsel women who screen positive for excessive alcohol use, prescription drug misuse, and illegal drug use.
- Refer women who disclose signs of symptoms of substance use disorder for more extensive treatment.
Background
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- Tobacco is the leading preventable cause of premature death for women residing in the U.S. While smoking rates have declined tobacco remains a leading risk for women of childbearing age and beyond.
- In 2018, 12% of adult women smoked cigarettes (CDC, 2019)
- In the 2019, 4.1% of female high school students smoked cigarettes; 6.2% smoked cigars and 1.8% used smokeless tobacco (CDC, 2019)
- Use of e-cigarettes has increased rapidly in the past few years, with large increases particularly among youth and young adults. In 2019, 27.4% of female high school students reported using e-cigarettes. (CDC, 2019)
- Alcohol-related mortality represents the third leading cause of preventable death for women in the U.S.
- Based on 2011-2013 data from the Behavioral Risk Factor Surveillance System, among nonpregnant women aged 18‐44 years, 53.6% used alcohol in the past 30 days, as did 10.2% of pregnant women of the same age.
- The prevalence of binge drinking in the past 30 days was estimated to be 18.2% among nonpregnant women and 3.1% among pregnant women.
- Non-medical use of prescription drugs is the third most common drug category of abuse after marijuana and tobacco. Accidental over-doses are amongst the most lethal consequences of prescription drug abuse.
- Approximately 18 million Americans over the age of 11 used prescription painkillers for non-medical purposes in 2017.
- In 2011, illicit drug use among women ages 12 and older was 6.5%: 4.9% reported using marijuana; 2.2% reported non-medical use of prescription drugs; 0.4% reported cocaine use and 0.3% reported using hallucinogens.
- Pregnancy-related consequences from substance use can occur before the woman realizes she is pregnant
- Alcohol consumption in pregnancy is the only cause of fetal alcohol spectrum disorders (FASD) which are estimated to affect at least 1% of all births in the United States.
- Fetal alcohol syndrome (FAS) is the most severe and disabling form of FASD. FAS only occurs if the embryo is exposed to alcohol in the first 8 weeks of gestation.
- NO amount of alcohol has proven safe for every embryo/fetus.
- Many tobacco related complications of pregnancy (ectopic pregnancy, abnormal placentation, spontaneous abortion) occur or are determined in the earliest weeks of gestation.
- Quick valid screening questions exist for use in the primary care setting to assess tobacco, alcohol, and other drug exposures.
- This NIDA tool (which includes an API link for EMR application) is available at www.drugabuse.gov/nmassist/. The NIDA Quick Screen is:
- In the past year how often have you used the following?
- 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily) [NOTE: since no amount of alcohol has been proven safe in pregnancy, women of childbearing potential should first be asked, “Do you ever drink beer, wine or mixed drinks?” before the first NIDA Quick Screen query]
- Tobacco products (never, once or twice, monthly, weekly, daily or almost daily).
- Prescription drugs for non-medical reasons (never, once or twice, monthly, weekly, daily or almost daily)
- Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily).
- In the past year how often have you used the following?
- Evidence-based interventions appropriate to busy primary care practices are available to address these exposures include:
- the 5A approach for women who screen positive for tobacco use (see below);
- the SBIRT approach for women who screen positive for alcohol, non-medical use of prescription drugs and illegal (see below)
- useful guidance is available at www.drugabuse.gov/nmassist/
- The 5A Approach
- The “5-A” model has been shown to markedly increase cessation rates compared to no professional engagement. (ACOG Women’s Health Care, 3rd ed, 2007).
- Use of the 5 A’s can take less than 3 minutes.
- The model can be employed by physicians, nurses, dentists, psychologists, social workers and others:
- Ask about tobacco use:
- Identify and document tobacco use status for every patient at every visit. [This can be achieved by preparing the person who collects and records the vital signs to add a query on tobacco use to their routine responsibilities].
- Advise to quit:
- In a clear, strong, and personalized manner, urge every tobacco user to quit. This can be achieved by the primary care provider stating something such as “Quitting is one of the most important things you can do for your health today and long into the future”; if the woman desires pregnancy or is at risk for an unintended pregnancy, the provider might state, “Quitting is one of the most important things you can do for your own health, the health of any pregnancies in your future and the health of your infant and child”.
- Assess willingness to make a quit attempt:
- Is the tobacco user willing to make a quit attempt at this time? [This can be achieved by asking something direct such as “What would you like to do about your smoking?” If she is ready to quit, encourage her to set a quit date within the next 30 days].
- Assist in quit attempt:
- For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. [This can be achieved by the primary care provider doing this themselves or referring the woman to a specific person in the clinical setting who has been designated the office champion for smoking cessation. This person can them provide the woman with specific strategies for becoming tobacco free (including the options of using local support groups, the state’s quit line, the option of pharmacotherapy, etc.]. For patients unwilling to quit, reinforce the health benefits and indicate you and your staff are there to provide support when she is ready. If your office has appointed an office champion for smoking cessation, the clinician could suggest the patient meet with her to discuss personal barriers to becoming smoke free.
- Arrange follow-up:
- For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. [The provider should develop a reminder system to assure follow-up occurs at the designated time; the follow-up call can be made by the office champion or some other person in the office; if the latter, the woman should be advised of who will be calling them]. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
- Ask about tobacco use:
- The SBIRT Approach:
- “Screening, Brief Intervention, Referral to Treatment” (SBIRT) is designed for use by providers who do not specialize in addiction treatment.
- The SBIRT approach is easy to learn relative to other behavioral treatment techniques. Go to http://www.bu.edu/bniart/sbirt-in-health-care/ to learn how to use this approach in your office.
- SBIRT has been demonstrated to be effective in reducing risky alcohol use when provided by a primary care provider or other qualified health care professional (e.g. registered nurse, social worker, physician assistant).
- Screening: (Discussed in previous section) Quickly assesses the degree of alcohol use and identifies the appropriate level of treatment (brief intervention and/or referral).
- Brief Intervention:
- Focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
- Gives information about their substance use based on their risk assessment scores.
- Advises in clear, respectful terms to decrease or abstain from substance use.
- Encourages to set goals to decrease substance use and to identify specific steps to reach those goals.
- Teaches behavior change skills that will reduce substance use and limit negative consequences.
- Referral to Treatment:
- Provides those identified as needing more extensive treatment with access to specialty care.
- The primary care practice should have established linkages to specialty addiction care to allow quick and seamless referral for women who continue risky drinking behaviors or show signs of alcohol dependence.
- Providers in underserved areas without appropriate referral resources should not be dissuaded from the “screening and brief intervention” portions of the approach as they have been demonstrated to have their own impact on individuals engaged in or approaching risky alcohol intake.
- Be clear and direct in advising smoking cessation (e.g. “It is my recommendation for your health and the health of any children you may have that you stop using all tobacco. I know this is a difficult process but my team and I are here to help you when you are ready. Can we talk about your readiness and some strategies today?”
- Help women understand that supports for discontinuing smoking are greatest prior to conception and that some of the complications caused by tobacco may exercise their influence even before she is aware she is pregnant.
- Be very clear with every woman who indicates she ever drinks any beer, alcohol or wine that no amount of alcohol has been proven safe in pregnancy and that some of alcohol’s most severe harms occur before women are aware they have conceived — therefore, the safest choice is to avoid ALL alcohol if she might become pregnant (having intercourse without using an effective contraceptive method).
- The partners’ use of alcohol, tobacco, and illegal drugs may have a big influence on the woman’s ability to discontinue use. This influence should be explored in women reticent to discontinue use and in women who are unsuccessful.
- Second hand smoke is linked to compromised health outcomes for fetuses, newborns, children and adults. Therefore, strategies to reduce exposures, especially if partner smokes, should be explored for all women and especially for women planning to become pregnant. Possible strategies to diminish risk are:
- No smoking in cars where woman is passenger
- Making inside the home a “no smoking” zone
- Avoiding enclosed spaces where smoking takes place such as parties, etc.