Adaption of 5 A's for use in smoking cessation during pregnancy

STEP 1: Ask

Recommendation:

Ask the patient about her smoking status.

Action:

Given high nondisclosure rates, identification of the pregnant smoker can be difficult. Specific strategies to identify smoking women include:

1. Use multiple choice questions when assessing whether a patient smokes. The following multiple choice question is recommended in either oral or written form.

Which of the following describes you best?

a. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime.

b. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.

c. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.

d. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant.

e. I smoke regularly now, about the same as BEFORE I found out I was pregnant.

2. Focus particular attention on women who report that they stopped smoking after conception. About half of nondisclosers in one series reported quitting after conception.

3. Consider using urinary cotinine measurements in women who report smoking as an objective measure of smoking exposure: Set goals for lowering this level. The routine use of urinary cotinine to confirm nonsmoking status is controversial given the ethical concerns and potential negative impact on the patient-doctor relationship. Until further guidelines and recommendations are available, it is not recommended.

STEP 2: Advise

Recommendation:

Provide clear strong advice to quit with personalized messages about the impact of smoking and quitting on mother and fetus.

Action:

1. Discuss the risks of smoking during pregnancy: low birth weight, placental abruption, placenta previa, premature delivery, stillbirth, preterm premature rupture of membranes.

2. If the patient has had a history of a complicated pregnancy, discuss how smoking may have contributed to this complication.

3. Discuss risks of secondary smoke, particularly for patients with children at home; SIDS, upper respiratory infections, otitis media asthma, pneumonia.

4. Recommend that the patient quit as soon as possible for maximal benefit; however, quitting at any time during pregnancy has some benefit.

STEP 3: Assess

Recommendation:

Assess the willingness of the patient to make a quit attempt within the next month.

Action:

Ask, "Quitting smoking is one of the most important things you can do for your health and the health of your baby. If we help you, are you willing to try?"

STEP 4: Assist

Recommendation:

Assist smoker in quitting.

Action:

1. Provide pregnancy-specific, self-help smoking cessation materials; multi-lingual educational packets available on the web: http://www.modimes.org.

2. Encourage the use of problem solving methods and skills for cessation:

Review withdrawal symptoms.

Identify "high risk situations" where they are more likely to relapse and set up strategies for avoiding them.

Strongly consider referral to social worker who can help patient gain access to services available to minimize stressors at home.

Consider referral to coping and stress management program.

3. Encourage patient to seek family and social support:

Identify non-smoking individuals, particularly successful quitters that can be supportive.

Offer referral to smoking partner for smoking cessation.

Patient should inform family that they intend to quit smoking during the pregnancy and ask for their support (ie, not smoking in the same room).

4. Consider pharmacotherapy for patients who smoke 10 cigarettes or more and are unable to quit. Use lowest dose necessary.

Bupropion

Nicotine replacement therapy

STEP 5: Arrange

Recommendation:

Assess smoking status throughout pregnancy and encourage cessation for continuing smokers.

Action:

1. Place a label on each chart that identifies the patient as a smoker.

2. Ask about smoking at each visit.

3. If still smoking, encourage cessation and consider adjunct pharmacotherapy as outlined in next section.

SIDS: sudden infant death syndrome.

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Adaption of 5 A's for use in smoking cessation during pregnancy