HELPING PREGNANT WOMEN AND NEW MOTHERS QUIT SMOKING

Quitting smoking is never easy. Pregnant women and mothers, who face many new and unique stresses, may find the task especially challenging. But these women reap tremendous health rewards for themselves and their babies when they stop smoking.

Smoking cessation is especially crucial for Aboriginal women. The Heart and Stroke Foundation reports that 60 per cent of Aboriginal women aged 15 or older are regular smokers (compared to an overall 26 per cent rate for Canadian women). In the Northwest Territories, up to 80 per cent of Inuit women are smokers. And a study from the University of Manitoba found that Aboriginal women were twice as likely as non-Aboriginal women to smoke during pregnancy (53 per cent vs. 26 per cent).

Unfortunately, mainstream "quit smoking" programs have not been particularly effective in Aboriginal communities. Some programs depict tobacco as a negative or evil substance - an approach that conflicts with the traditional Aboriginal view of tobacco as a sacred plant. These programs also tend to ignore the living situations faced by many Aboriginal women.
Tobacco cessation programs for Aboriginal women must show appreciation for the woman as a unique person belonging to a unique culture. At the same time, they must inform women about the real dangers of smoking during pregnancy and motherhood. Community health workers should not water down that message. However, they need to deliver it in a non-judgmental way that emphasizes the good of mother and baby.

How does smoking affect an unborn baby?

Cigarette smoke reaches the fetus through the placenta, the tissue that connects the mother and fetus. Among other important functions, the placenta provides nutrients to the fetus. When nicotine and carbon monoxide (toxins in cigarette smoke and second-hand smoke) enter the body, they reach the placenta and deprive it of oxygen and nutrients. As a result, the baby is also deprived.

Smoking during pregnancy increases the risk of miscarriage, a stillborn baby, a premature baby, or a baby with birth defects. Smoking damages the fetal lungs, which develop early and are exposed longer than other organs to tobacco toxins. It also harms the fetal brain by interfering with the placental exchange of oxygen.

Pregnant women who smoke are more likely to give birth to a low birth weight baby. This is a concern because smaller babies are more likely to be ill, to need special care, and to stay longer in hospital. They are also more likely to die at birth or within the first year.

A pregnant woman who smokes runs a higher risk of placenta previa (abnormal implantation of the placenta), abruptio placenta (premature separation of the placenta), or ruptured membranes (when the amniotic sac breaks prematurely).

The most serious health risk of smoking is the higher likelihood of having a baby die of Sudden Infant Death Syndrome (SIDS). SIDS is the leading cause of death in Canada for infants one month to one year old (see article on SIDS in this issue of In Touch). The risk of SIDS triples if the mother has smoked during pregnancy, and doubles if the child is only exposed to cigarette smoke after birth.

Environmental tobacco smoke (ETS)

Non-smoking pregnant women who live or work in a smoke-filled environment can suffer the same harmful effects as women who smoke.

Studies show that second-hand smoke (or ETS) is dangerous to the fetus and baby. ETS is a mixture of exhaled smoke from the tobacco user, side-stream smoke from the smouldering tobacco between puffs, and contaminants emitted into the air during and between puffs. It contains more than 4,000 substances, including large amounts of ammonia, benzene, carbon monoxide, nicotine, carcinogens and other irritants.
Infants have sensitive, developing lungs, and they breathe about 40 times per minute compared to 18 times per minute for an adult. This makes them vulnerable to the effects of tobacco smoke.

A study by researchers at Toronto's Hospital for Sick Children and the University of Maryland found significantly higher levels of nicotine in the lung tissue of babies who died from SIDS than in non-SIDS babies. This study doesn't suggest that second-hand smoke causes SIDS, but it highlights that second-hand smoke is risky for infants who are susceptible to SIDS.

ETS poses a major environmental health challenge in our society, especially since its harmful effects are often felt by non-smokers - like babies and children - against their will.

RESPONDING TO CLIENTS' CONCERNS

Despite recognizing the health risks of smoking, pregnant women and new mothers may have concerns or misperceptions about quitting. Here's how health professionals can address statements like these:

"I'm already six months along in my pregnancy. There's no point in quitting now." No matter when in the pregnancy a woman stops smoking, there are health benefits. If she gets pregnant and is using tobacco, she should try to quit. The earlier she ceases, the better for her and the baby. Of course, the best time to quit is before getting pregnant - ideally, three months before conception.

"I've cut down on the amount I smoke. That's the best I can do." This is a step in the right direction. But the only way to really protect the unborn baby is to quit. Women who reduce their smoking may inhale more deeply, or take more puffs, in an attempt to get the same amount of nicotine as before.

"I don't want to quit - I'm afraid of gaining weight." A woman needs to gain weight during pregnancy. The fetus depends on the mother to consume nutritious foods. If a mother eats healthy food, the weight gain will generally be fine. Safe exercise is good for the mother and the baby, and is recommended.

"I don't want to quit - smoking helps me handle stress." It's important to find new ways to relax - ones that are much better for the woman and the unborn baby. Relaxation or breathing exercises can help. Finding alternative activities - especially those that involve use of the hands - can be useful.

"I'll quit while I'm pregnant, but I plan to start smoking again afterwards." Tobacco smoke is harmful to infants, too. It results in an increased chance of SIDS, respiratory illness, impaired lung function, coughing and wheezing, asthma, allergies, middle ear disease, developmental delays, and future smoking behaviour.

"I'm breastfeeding. Is it safe to smoke?" Breastfeeding is recommended even if the mother smokes. She should know, however, that tobacco toxins reach her baby through the breast milk. Heavy smokers may have decreased milk production and lower vitamin C levels in their milk. Their babies may be at greater risk for nausea, colic and diarrhea. Even moderate levels of nicotine and other chemicals stay in breast milk for up to five hours after the last cigarette. If a mother continues to smoke, she should do so after breastfeeding (not before), and she should smoke in an area away from the baby.

"Is it safe to use nicotine replacement therapy while I'm pregnant and trying to quit smoking?" Nicotine replacement therapy (as gum, a patch, an inhaler, or spray) releases nicotine into the body. Nicotine is a poison to the mother and fetus. Research shows, however, that nicotine replacement therapy poses less risk to the fetus than does continued smoking by the mother, particularly if she is a heavy smoker. The daily dose of nicotine is less than if the woman smokes, and she isn't exposed to other toxic constituents of tobacco. A woman should discuss this strategy with her doctor.

"Can I use nicotine replacement therapy while breastfeeding?" Since nicotine passes readily into breast milk, ideally it should not be taken in any form during breastfeeding.

MAKING "QUIT SMOKING" PROGRAMS EFFECTIVE

Target and tailor the interventions to the Aboriginal population, and specifically pregnant women and mothers. Acknowledge the traditional respect accorded tobacco, the extra pressures faced in the Aboriginal community, and the extra stresses faced by a pregnant woman and mother. Look specifically at each woman's life demands and how she will benefit from quitting smoking.

Start interventions to help women quit as early as possible - before pregnancy is ideal. Public education messages can be directed to women smokers and their partners who intend to have children. During pregnancy, interventions should take place as soon as possible.

Understand that quitting is a process. Distinct stages are involved; each calls for a different form of support. The stages are: precontemplation (the woman is not thinking about quitting); contemplation (she's seriously thinking about quitting in the next six months or so); preparation (she's committed to stop smoking - she's gathered resources, checked out programs, picked a date to quit); action (she's actively living out her plan to quit smoking); maintenance (she's working hard to prevent relapse); and relapse (she starts smoking again - many people make several attempts to quit before they finally succeed).

Include interventions to reduce smoking. Pregnant women who do not quit smoking should be encouraged to significantly reduce the amount they smoke.

Prepare the woman for challenges after birth. Sixty to 80 per cent of women who quit smoking during pregnancy relapse within six months after birth. The postpartum period has different stresses than pregnancy: caring for a new child, dealing with lack of sleep, finding time for one's self, and so on.

Get partners involved. Since 60 to 74 per cent of pregnant smokers live with partners who smoke, it may be helpful to provide strategies or programs to help that person quit, too. Second-hand smoke harms infants, so it's important that the partner (and others) not bring smoke into the environment.

Deliver information from a variety of sources such as community efforts, advertisement/media, workplace initiatives, public education, health professionals and peers. Combined effects can be effective.

Create a smoke-free environment for your client and family. Remind your client that smoking in the basement or beside a fan is not sufficient protection. Eliminating smoke from the home can be a sensitive and difficult issue, but it is important. You and your client might work on strategies like posting a friendly sign in the window asking people not to smoke inside, creating a family contract, and so on.


What happens to your body when you quit smoking?

Day One
After 20 minutes, blood pressure and pulse rate drop to normal. The temperature of the feet and hands returns to normal. After eight hours, blood levels of carbon monoxide fall to normal, and blood levels of oxygen rise to normal. After 24 hours, the chances of having a heart attack already decrease.

The First Week
Nerve endings start to re-grow. Your ability to smell and taste increases. Bronchial tubes relax, you breathe easier, and lung capacity increases.

The First Year
Coughing, sinus congestion, fatigue and shortness of breath all decrease. Cilia regrow in the lungs, improving the lungs' ability to handle mucus, stay clean, and fight infection.

Five Years Later
The death rate from lung cancer falls by nearly one-half.

Ten to 15 Years Later
Precancerous cells are replaced. The death rate from lung cancer falls further. The risk of coronary heart disease is now that of a nonsmoker.

A few strategies to stop smoking

· drink lots of water
· breathe deeply
· delay the first cigarette of the day
· be physically active
· get plenty of rest
· keep your hands busy
· give yourself a treat
· celebrate your success at all stages
· choose healthy foods
· keep a smoking diary in your cigarette pack
· encourage a friend to quit smoking with you
· socialize with non-smokers
· look for ways to make smoking more difficult
· take a "stop smoking" course
· relax and meditate
· write in a journal
· go to smoke-free places
· create a smoke-free home
· plan a "quit day"

Traditional tobacco use - not the same as smoking commercial tobacco

For Aboriginal people, tobacco has traditionally been seen as a gift from the Creator. One of the most respected plants, tobacco was burned in sacred ceremonies. Its smoke was believed to carry prayers to the Creator. Tobacco was thrown on fires before trying to communicate with the spirit world; thrown on water before travel to ensure safe passage; and smoked in a sacred pipe to cement political and economic agreements between tribes.

Traditionally, Aboriginal people used tobacco only in special ceremonies. That began changing when European settlers arrived in North America. These settlers traded a new type of tobacco used for recreational smoking. Tobacco did not lose its religious significance for Aboriginal people, but the original tobacco used for ceremonies became rare because it was no longer traded.

The tobacco in today's commercial cigarettes bears little resemblance to the indigenous plant used in traditional ceremonies. For 500 years, tobacco has been selectively bred to increase its nicotine potency. It is now a highly addictive substance. In today's Aboriginal community, the respect afforded to traditional tobacco is often overshadowed by widespread misuse of commercial tobacco.

An estimated 60 per cent of Aboriginal people in Canada are smokers, compared to 23 per cent of the general Canadian population. Among Aboriginal tobacco users, 72 per cent of Inuit were smokers compared to 56 per cent of Indians and 57 per cent of Metis. Aboriginal people in the Northwest Territories were the most likely to smoke (71 per cent) while those in British Columbia were the least likely to smoke (51 per cent).