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Taylor L, Claire R, Campbell K, Coleman-Haynes T, Leonardi-Bee J, Chamberlain C, Berlin I, Davey MA, Cooper S, Coleman T. Fetal safety of nicotine replacement therapy in pregnancy: systematic review and meta-analysis. Addiction 2021; 116:239-277. [PMID: 32621526 DOI: 10.1111/add.15185] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/02/2020] [Accepted: 06/05/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND AIMS Smoking in pregnancy causes substantial avoidable harm to mothers and offspring; nicotine replacement therapy (NRT) may prevent this, and is used to help women to quit. A recently updated Cochrane Review of randomized controlled trials (RCTs) investigating impacts of NRT in pregnancy focuses primarily on efficacy data, but also reports adverse impacts from NRT. Here we identify and summarize NRT impacts on adverse pregnancy outcomes reported in non-randomized controlled trials (non-RCTs). METHODS Systematic reviews and meta-analyses of RCTs and non-RCT studies of NRT in pregnancy, with design-specific risk of bias assessment and grading of recommendations, assessment, development and evaluations (GRADE) criteria applied to selected outcomes. FINDINGS Relevant Cochrane Review findings are reported alongside those from this new review. Seven RCTs were included; n = 2340. Nine meta-analyses were performed; non-statistically significant estimates indicated potentially reduced risk from NRT compared with smoking for mean birth weight, low birth weight, preterm birth, intensive care admissions, neonatal death, congenital anomalies and caesarean section and potentially increased risks for miscarriage and stillbirth. GRADE assessment for mean birth weight and miscarriage outcomes indicated 'low' confidence in findings. Twenty-three non-RCTs were included; n = 931 163. Eleven large studies from five routine health-care cohorts reported clinical outcomes; 12 small studies investigated mainly physiological outcomes within in-patient women given NRT. Findings from meta-analyses for congenital anomalies, stillbirth and preterm birth were underpowered and not in a consistent direction; GRADE assessment of confidence in findings was 'very low'. Routine health-care studies were of higher quality, but implications of reported findings were unclear as there was inadequate measurement and reporting of women's smoking. CONCLUSIONS Available evidence from randomized controlled trials and non-randomized comparative studies does not currently provide clear evidence as to whether maternal use of nicotine replacement therapy during pregnancy is harmful to the fetus.
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Affiliation(s)
- Lauren Taylor
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Ravinder Claire
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Katarzyna Campbell
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Tom Coleman-Haynes
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Jo Leonardi-Bee
- Centre for Evidence Based Healthcare, Division of Epidemiology and Public Health, Clinical Sciences Building Phase 2, University of Nottingham, Nottingham, UK
| | | | - Ivan Berlin
- Department of Pharmacology, Sorbonne Université, Faculté de médecine-Hôpital Pitié-Salpetrière, Paris, France
| | - Mary-Ann Davey
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Sue Cooper
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Tim Coleman
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, UK
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Lee PN, Fariss MW. A systematic review of possible serious adverse health effects of nicotine replacement therapy. Arch Toxicol 2017; 91:1565-1594. [PMID: 27699443 PMCID: PMC5364244 DOI: 10.1007/s00204-016-1856-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 09/22/2016] [Indexed: 12/11/2022]
Abstract
We conducted a systematic literature review to identify and critically evaluate studies of serious adverse health effects (SAHEs) in humans using nicotine replacement therapy (NRT) products. Serious adverse health effects refer to adverse events, leading to substantial disruption of the ability to conduct normal life functions. Strength of evidence evaluations and conclusions were also determined for the identified SAHEs. We evaluated 34 epidemiological studies and clinical trials, relating NRT use to cancer, reproduction/development, CVD, stroke and/or other SAHEs in patients, and four meta-analyses on effects in healthy populations. The overall evidence suffers from many limitations, the most significant being the short-term exposure (≤12 weeks) and follow-up to NRT product use in most of the studies, the common failure to account for changes in smoking behaviour following NRT use, and the sparse information on SAHEs by type of NRT product used. The only SAHE from NRT exposure we identified was an increase in respiratory congenital abnormalities reported in one study. Limited evidence indicated a lack of effect between NRT exposure and SAHEs for CVD and various reproduction/developmental endpoints. For cancer, stroke and other SAHEs, the evidence was inadequate to demonstrate any association with NRT use. Our conclusions agree with recent statements from authoritative bodies.
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Affiliation(s)
- Peter N. Lee
- P N Lee Statistics and Computing Ltd, 17 Cedar Road, Sutton, Surrey SM2 5DA UK
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Cummins SE, Tedeschi GJ, Anderson CM, Zhu SH. Telephone Intervention for Pregnant Smokers: A Randomized Controlled Trial. Am J Prev Med 2016; 51:318-26. [PMID: 27056131 DOI: 10.1016/j.amepre.2016.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 02/04/2016] [Accepted: 02/16/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Pregnant smokers are advised to quit; however, many struggle to do so. Behavioral counseling can increase quitting success, but the efficacy of telephone counseling for pregnant smokers has not been established. This study tests the efficacy of pregnancy-specific counseling, embedded in the ongoing operations of a state quitline. DESIGN In this two-group RCT, participants were randomly assigned to the intervention (telephone counseling plus self-help materials, n=584) or the control group (self-help materials only, n=589). SETTING/PARTICIPANTS Participants were pregnant smokers (N=1,173) in the first 27 weeks of gestation who called a state quitline between September 2000 and May 2003 for help with quitting. INTERVENTION The primary component of the intervention was telephone counseling using a semi-structured protocol developed specifically for pregnant smokers. It drew its basic structure and clinical content from a previously tested counseling protocol for adult quitline callers, while including pregnancy-specific content and additional counseling sessions (nine rather than the standard five). MAIN OUTCOME MEASURES Subjects were evaluated on prolonged abstinence at the third trimester (about 29 weeks' gestation) and at 2 and 6 months postpartum. Data were analyzed in 2015. RESULTS Abstinence was higher for the intervention than the control group at the end of pregnancy (30-day abstinence, 29.6% vs 20.1%; p<0.001); 2 months postpartum (90-day abstinence, 22.1% vs 14.8%; p<0.001); and 6 months postpartum (180-day abstinence, 14.4% vs 8.2%; p<0.001). Cotinine-corrected (≤13 ng/mL) 7-day abstinence rates at the end of pregnancy supported the intervention effect (35.8% vs 22.5%, p<0.001). CONCLUSIONS A pregnancy-specific counseling protocol, embedded in a state quitline, was effective in helping pregnant smokers quit and stay quit postpartum. Wide adoption of this intervention could help reduce the rate of maternal smoking and prevent its devastating health consequences. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02144883.
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Affiliation(s)
- Sharon E Cummins
- Department of Family Medicine and Public Health, University of California, San Diego, California; Moores Cancer Center, University of California, San Diego, California
| | - Gary J Tedeschi
- Moores Cancer Center, University of California, San Diego, California
| | | | - Shu-Hong Zhu
- Department of Family Medicine and Public Health, University of California, San Diego, California; Moores Cancer Center, University of California, San Diego, California.
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Abstract
Objective: To determine the safety and efficacy of pharmacologic therapy for smoking cessation in pregnancy by conducting a review of current literature, focusing on controlled clinical trials. Data Sources: A MEDLINE search (1966–May 2006) of English-language, human clinical trials was conducted. Key search terms included nicotine, nicotine replacement therapy, bupropion, smoking cessation, and pregnancy. In addition, relevant articles were cross-referenced to screen for additional information. Study Selection/Data Extraction: Studies were chosen for further review if they were randomized, controlled, long-term evaluations of the safety and/or efficacy of pharmacologic therapy for smoking cessation in pregnancy. A total of 5 trials met the criteria for review. Data Synthesis: Controlled clinical trials of smoking cessation therapy in pregnant women are limited. Three trials have examined the long-term use of nicotine replacement products. Neither of the 2 placebo-controlled trials found a statistically significant difference in abstinence rates between women receiving transdermal nicotine replacement therapy (NRT) and placebo. However, transdermal nicotine products appeared to be safe in this population. No long-term studies have evaluated use of other nicotine replacement products in pregnant women. Bupropion has demonstrated efficacy in smoking cessation in pregnancy, but the data are limited. Conclusions: Transdermal NRT appears to be safe in pregnant women, although its efficacy is unclear. Information on other NRT formulations in pregnancy is unavailable. Bupropion may be a nonnicotine alternative for smoking cessation in pregnancy, but data are currently incomplete. Further studies are needed to determine the ideal population for treatment, the timing of initiation, appropriate monitoring, and the optimal length of therapy.
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Affiliation(s)
- Curtis L Smith
- CURTIS L SMITH PharmD BCPS, Professor, Department of Pharmacy Practice, College of Pharmacy, Ferris State University, Lansing, MI
| | - Erin K Rivard
- ERIN K RIVARD PharmD, at time of writing, PharmD Student, College of Pharmacy, Ferris State University; now, Community Pharmacist, Lowell, MI
| | - Cathleen M Edick
- CATHLEEN M EDICK PharmD, Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, Ferris State University
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Saba M, Bittoun R, Kritikos V, Saini B. Smoking cessation in community pharmacy practice-a clinical information needs analysis. SPRINGERPLUS 2013; 2:449. [PMID: 24058894 PMCID: PMC3777019 DOI: 10.1186/2193-1801-2-449] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 08/23/2013] [Indexed: 02/08/2023]
Abstract
Background With the emerging role of pharmacists in implementing smoking cessation services and the recent evidence about smoking cessation pharmacotherapies, a needs analysis to assess baseline knowledge about current smoking cessation practice is needed; hence, training and development in this area can target possible ‘gaps’. Objective This study aimed at exploring pharmacy students’ knowledge about and attitudes toward smoking cessation, as compared to practicing community pharmacists and smoking cessation educators. The overall objective was to uncover underlying ‘gaps’ in pharmacy-based smoking cessation practice, particularly clinical gaps. Setting Final-year pharmacy students at the University of Sydney, practicing community pharmacists and smoking cessation educators in Australia. Method As no previous standard pharmacist-focused smoking cessation knowledge questionnaires exist, a review of the literature informed the development of such a questionnaire. The questionnaire was administered to a cohort of fourth-year pharmacy students at the University of Sydney, practicing pharmacists and smoking cessation educators. Data analysis was performed using Predictive Analytics SoftWare (PASW® Statistics 18). Mean total scores, independent t-tests, analysis of variances and exploratory factor analysis were performed. Main outcome measure To determine areas of major clinical deficits about current evidence related to smoking cessation interventions at the pharmacy level. Results Responses from 250 students, 51 pharmacists and 20 educators were obtained. Smoking educators scored significantly higher than pharmacists and students (P < .05), while score differences in the latter two groups were not statistically significant (P > .05). All groups scored high on ‘general’ knowledge questions as compared to specialised pharmacologic and pharmacotherapeutic questions. All respondents demonstrated positive attitudes toward the implications of smoking cessation. Factor analysis of the 24-item knowledge section extracted 12 items loading on 5 factors accounting for 53% of the total variance. Conclusions The results provide a valid indication of ‘gaps’ in the practice of up-to-date smoking cessation services among Australian pharmacy professionals, particularly in clinical expertise areas involving assessment of nicotine dependence and indications, dosages, adverse effects, contraindications, drug interactions and combinations of available pharmacotherapies. These gaps should be addressed, and the results should inform the design, implementation and evaluation of a pharmacy-based educational training program targeting current clinical issues in smoking cessation.
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Affiliation(s)
- Maya Saba
- Faculty of Pharmacy, The University of Sydney, Sydney, NSW 2006 Australia
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Myung SK, Ju W, Jung HS, Park CH, Oh SW, Seo HG, Kim HS. Efficacy and safety of pharmacotherapy for smoking cessation among pregnant smokers: a meta-analysis. BJOG 2012; 119:1029-39. [DOI: 10.1111/j.1471-0528.2012.03408.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Forinash AB, Pitlick JM, Clark K, Alstat V. Nicotine replacement therapy effect on pregnancy outcomes. Ann Pharmacother 2010; 44:1817-21. [PMID: 20978216 DOI: 10.1345/aph.1p279] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review data assessing the effects of nicotine replacement therapy (NRT) during pregnancy on fetal, neonatal, and maternal outcomes. DATA SOURCES A literature search of PubMed (1966-July 2010) was performed using the terms smoking, smoking cessation, pregnancy, and nicotine replacement therapy. Bibliographies and the Cochrane Database were reviewed to identify additional relevant articles. STUDY SELECTION AND DATA EXTRACTION All studies including humans and published in English with data describing NRT effects on pregnancy outcomes or malformations as a primary or secondary outcome were evaluated. DATA SYNTHESIS Currently, behavior modification therapy is recommended for smoking cessation in pregnancy as first-line treatment, but NRT should be offered to patients who are not successful. NRT is currently a pregnancy category D medication. Pregnancy outcomes and malformation rates for NRT in pregnancy were evaluated as either primary or secondary outcomes in several trials. Four studies examined pregnancy outcomes after a full course of nicotine gum or patch therapy. NRT use significantly decreased the risk of preterm delivery and low birth weight compared to that of smokers. Only 1 study evaluated the risk of malformations after exposure to the NRT patch during the first trimester. In a retrospective analysis, NRT users had an increased risk for any fetal malformation but not for major or musculoskeletal ones. However, no adjustments were made for many known factors associated with malformations. CONCLUSIONS Behavior modification therapy should always be the first method tried for smoking cessation in the pregnant population. If behavior modification therapy is attempted without success, NRT should be offered because of decreased risk for low birth weight and preterm delivery compared to continued smoking. Additionally, NRT does not appear to increase the risk for malformations.
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Affiliation(s)
- Alicia B Forinash
- Department of Pharmacy Practice, St. Louis College of Pharmacy, MO, USA.
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Ashwin CA, Watts K. Women's use of nicotine replacement therapy in pregnancy—a structured review of the literature. Midwifery 2010; 26:304-10. [DOI: 10.1016/j.midw.2008.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Revised: 08/12/2008] [Accepted: 08/20/2008] [Indexed: 10/21/2022]
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Oncken CA, Kranzler HR. What do we know about the role of pharmacotherapy for smoking cessation before or during pregnancy? Nicotine Tob Res 2009; 11:1265-73. [PMID: 19717542 DOI: 10.1093/ntr/ntp136] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
SIGNIFICANCE Given the substantial health risks of smoking during pregnancy, and the potential of pharmacotherapy to enhance quit rates, a need exists to examine the utility of pharmacotherapy for smoking cessation during pregnancy. LITERATURE REVIEW We briefly review the first-line medications that are recommended for smoking cessation in nonpregnant adults. Additionally, we review the toxicity of tobacco smoke and the potential risks of pharmacotherapy as evidenced by animal studies. We review in more detail studies conducted in pregnant women, including (a) observational studies, (b) short-term safety and longer term uncontrolled studies, and (c) randomized controlled clinical trials (both effectiveness and efficacy studies). DISCUSSION Because the safety and efficacy of pharmacotherapy for smoking cessation during pregnancy have not been established, no definitive recommendations can be made on the topic. Effectiveness trials have shown that nicotine replacement therapy (NRT) enhances smoking cessation during pregnancy, but efficacy trials have not shown an advantage for NRT compared with placebo treatment. Small sample size or poor medication compliance (with either the dose or the duration of treatment) may contribute to lack of efficacy in placebo-controlled NRT trials. However, these trials showed that NRT did not adversely affect birth outcomes and increased birth weight. Based on these findings and the fact that all medications have some risk, psychosocial interventions should be the first treatment option for pregnant smokers. Additional research is needed to determine fully the risks and benefits of the various pharmacotherapies for smoking cessation during pregnancy.
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Affiliation(s)
- Cheryl A Oncken
- Department of Medicine, MC 3940, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06030-3940, USA.
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Hurt RD, Renner CC, Patten CA, Ebbert JO, Offord KP, Schroeder DR, Enoch CC, Gill L, Angstman SE, Moyer TP. Iqmik – A form of smokeless tobacco used by pregnant Alaska natives: Nicotine exposure in their neonates. J Matern Fetal Neonatal Med 2009; 17:281-9. [PMID: 16147838 DOI: 10.1080/14767050500123731] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the concentration of nicotine and cotinine in maternal blood and neonatal cord blood among pregnant Alaska Native women and to assess the neonates for neurobehavioral effects. METHODS In a nonrandomized, clinical observational pilot trial, 60 pregnant Alaska Native women were enrolled for assessment of Iqmik (a mixture of leaf tobacco and ash) and other tobacco use during pregnancy and at delivery. Neonatal cord blood, nicotine and cotinine concentrations were obtained, and neonatal neurobehavioral effects were assessed using the Lipsitz scale. RESULTS At delivery, there were 22 subjects who reported using only Iqmik, and 10 who used other tobacco products. Subjects who reported using only Iqmik prior to delivery had higher concentrations of cotinine (167+/-116 vs. 81+/-100) in maternal blood (rank sum test, p=0.036) and higher concentrations of nicotine (8.4+/-7.3 vs. 4.4+/-5.1, p=0.048) and cotinine (153+/-115 vs. 70+/-95, p=0.048) in cord blood compared to subjects who reported using other tobacco products. Neurobehavioral signs as assessed by the Lipsitz score were increased in neonates born to mothers using only Iqmik (3.7+/-1.8, p=0.011), or to mothers using other tobacco products (3.4+/-1.4, p=0.034) compared to neonates born to women who reported no tobacco use (1.8+/-1.4). CONCLUSIONS Mothers who use Iqmik and their neonates have higher cotinine concentrations compared to mothers who use cigarettes and/or other forms of tobacco. Neurobehavioral signs occur in neonates born to women who use Iqmik but also in neonates born to mothers who use other forms of tobacco during pregnancy.
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Affiliation(s)
- Richard D Hurt
- Nicotine Dependence Center, Mayo Clinic, Rochester, MN 55905, USA.
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Thompson BL, Levitt P, Stanwood GD. Prenatal exposure to drugs: effects on brain development and implications for policy and education. Nat Rev Neurosci 2009; 10:303-12. [PMID: 19277053 PMCID: PMC2777887 DOI: 10.1038/nrn2598] [Citation(s) in RCA: 234] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effects of prenatal exposure to drugs on brain development are complex and are modulated by the timing, dose and route of drug exposure. It is difficult to assess these effects in clinical cohorts as these are beset with problems such as multiple exposures and difficulties in documenting use patterns. This can lead to misinterpretation of research findings by the general public, the media and policy makers, who may mistakenly assume that the legal status of a drug correlates with its biological impact on fetal brain development and long-term clinical outcomes. It is important to close the gap between what science tells us about the impact of prenatal drug exposure on the fetus and the mother and what we do programmatically with regard to at-risk populations.
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Affiliation(s)
- Barbara L Thompson
- Department of Pharmacology, Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN 37232, USA
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Ashwin C, Watts K. Exploring the views of women on using nicotine replacement therapy in pregnancy. Midwifery 2009; 26:401-6. [PMID: 19185398 DOI: 10.1016/j.midw.2008.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 11/02/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE to explore women's views surrounding the use of nicotine replacement therapy (NRT) to aid smoking cessation. DESIGN AND SETTING a qualitative approach using semi-structured interviews undertaken on 10 pregnant women in a semi-rural area of England. FINDINGS the two main themes that emerged from the study were that NRT was an important component in stopping smoking, but this was in conjunction with support given by the midwife advisor. Both themes appeared to be equally important to the women in aiding their attempts at smoking cessation. Also, the importance of tailored interventions should not be dismissed when aiding women in smoking cessation. CONCLUSIONS exploring the views of women enabled the researchers to gain a greater understanding of the problems and achievements that women encountered when using NRT as an aid to stop smoking during pregnancy. The study also demonstrated that smoking cessation strategies can be successful if they are tailored to the individual needs of each woman, taking into account her dependency, domestic circumstances and willingness to change. IMPLICATIONS FOR PRACTICE the findings of this study add to the available research surrounding the efficacy of NRT in pregnancy. There is little evidence that the views of pregnant women have been taken into account prior to this study; as such, this report offers a different dimension to the available evidence. Although these findings could be adopted and utilized by practitioners, there is still the need for further research in this area on a larger scale.
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Affiliation(s)
- Cathy Ashwin
- Academic Division of Midwifery, PGEC, Nottingham University Hospital NHS Trust, City Hospital Campus, Hucknall Road, Nottingham NG5 1PB, UK.
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Smoking in pregnancy and lactation: a review of risks and cessation strategies. Eur J Clin Pharmacol 2009; 65:325-30. [PMID: 19169678 DOI: 10.1007/s00228-008-0609-0] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 12/30/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Despite documented evidence of harm to fetus and infant, a substantial number of women continue to smoke during pregnancy and lactation. OBJECTIVE To examine the literature regarding smoking during pregnancy and breastfeeding to ascertain adverse effects as well as the efficacy of interventions to enable women to stop smoking in the perinatal period. STUDY DESIGN A comprehensive literature search was undertaken to identify all published studies reporting on smoking in pregnancy and lactation. MEDLINE, EMBASE, PUBMED, and Web of Science databases were searched for studies published in English from 1966 to 2008 that reported on smoking in pregnancy and breastfeeding, with information on adverse effects and on all forms of smoking cessation, including behavioral interventions, nicotine replacement therapy, and pharmacotherapy such as antidepressants. RESULTS There is evidence that smoking in pregnancy and lactation may cause many adverse affects in the perinatal period, childhood, and up to adulthood. These adverse effects include infertility, ectopic pregnancy, spontaneous abortion, placenta insufficiency, low birth weight, fetal growth restriction, preterm delivery, orofacial clefts, SIDS, craniosynostosis, clubfoot, childhood respiratory disease, attention deficit disorder, and some childhood cancers. A number of strategies have been developed to assist pregnant women in quitting smoking, including both behavioral interventions and pharmacological therapies, such as nicotine replacement and antidepressant therapy. CONCLUSIONS Behavioral interventions report only modest success rates. Nicotine replacement therapy and antidepressants appear to be safe to use in pregnancy, but do not achieve a substantially higher success rate for quitting.
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If nicotine is a developmental neurotoxicant in animal studies, dare we recommend nicotine replacement therapy in pregnant women and adolescents? Neurotoxicol Teratol 2008; 30:1-19. [PMID: 18380035 DOI: 10.1016/j.ntt.2007.09.002] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tobacco use in pregnancy is a leading cause of perinatal morbidity and contributes in major ways to attention deficit hyperactivity disorder, conduct disorders and learning disabilities that emerge in childhood and adolescence. Over the past two decades, animal models of prenatal nicotine exposure have demonstrated that nicotine is a neurobehavioral teratogen that disrupts brain development by preempting the natural, neurotrophic roles of acetylcholine. Through its actions on nicotinic cholinergic receptors, nicotine elicits abnormalities of neural cell proliferation and differentiation, promotes apoptosis and produces deficits in the number of neural cells and in synaptic function. The effects eventually compromise multiple neurotransmitter systems because of the widespread regulatory role of cholinergic neurotransmission. Importantly, the long-term alterations include effects on reward systems that reinforce the subsequent susceptibility to nicotine addiction in later life. These considerations strongly question the appropriateness of nicotine replacement therapy (NRT) for smoking cessation in pregnant women, especially as the pharmacokinetics of the transdermal patch may actually enhance fetal nicotine exposure. Further, because brain maturation continues into adolescence, the period when smoking typically commences, adolescence is also a vulnerable period in which nicotine can change the trajectory of neurodevelopment. There are also serious questions as to whether NRT is actually effective as an aid to smoking cessation in pregnant women and adolescents. This review considers the ramifications of the basic science findings of nicotine's effects on brain development for NRT in these populations.
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Abstract
OBJECTIVE To assess how often pregnant and postpartum smokers use medications and how often obstetric providers recommend them. METHODS We analyzed end-of-pregnancy and 3-month postpartum surveys of 296 pregnant smokers enrolled in a randomized controlled trial of telephone counseling for smoking cessation that did not include medication. Patients were asked whether any obstetric provider discussed cessation medication and whether they had used medication. RESULTS At end of pregnancy, 29.3% of respondents reported discussing a cessation medication with their obstetric providers, more often nicotine replacement (26.5%) than bupropion (12.2%) (P=.001). Ten percent of trial respondents used a medication while pregnant (7.4% nicotine replacement, 3.4% bupropion, P=.023). Obstetricians discussed medication with 29.4% of smokers at the postpartum visit; 14.3% of postpartum smokers used medication. Contrary to guidelines, women who smoked more cigarettes per day or had already tried quitting during pregnancy were not more likely to use medication or to discuss medication with their provider. Medication use was associated with older age, more education, living with a partner, a previous birth, having an obstetric provider who discussed medication, and having private health insurance in a state whose Medicaid program did not cover cessation medications (all P<.05). CONCLUSION Pregnant women are more reluctant to use cessation medications than clinical guidelines recommend. More pregnant smokers might use cessation medications if their obstetricians discussed them routinely and if health insurance covered their cost. LEVEL OF EVIDENCE II.
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Jordan TR, Dake JR, Price JH. Best practices for smoking cessation in pregnancy: do obstetrician/gynecologists use them in practice? J Womens Health (Larchmt) 2006; 15:400-41. [PMID: 16724888 DOI: 10.1089/jwh.2006.15.400] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess Ohio obstetrician/gynecologists' perceptions and use of the 5As method of smoking cessation (ask, advise, assess, assist, and arrange) with pregnant patients who smoke. METHODS A three-wave mailing procedure was used with a statewide random sample of obstetrician/ gynecologists who responded to a valid and reliable 31-item questionnaire. RESULTS Regarding the 5As method of smoking cessation, almost all (98%) asked their pregnant patients about smoking, but fewer respondents engaged in advising (66%), assessing (42%), assisting (29%), and arranging for follow-up visits or referrals (6%). Higher efficacy expectations were associated with greater use of the 5As method (r = 0.52, p < 0.001). A majority believed that two cessation activities would result in smoking cessation in pregnant smokers: explaining the dangers of smoking (65%) and referring pregnant smokers to smoking cessation programs (57%). However, 26% of physicians reported that they were "slightly confident" or "not confident at all" in their ability to refer pregnant smokers to such programs, and 6% of physicians reported always providing smoking cessation referrals. A significant proportion of respondents believed that prenatal smoking would not cause severe effects for the unborn child but would likely lead to moderate (46%) or minor (3%) health effects. CONCLUSION Obstetrician/gynecologists face many competing demands for their time and energy, yet 62% believed smoking cessation advice would be of significant value. Physicians with higher levels of efficacy expectations reported significantly greater use of the 5 As. Future research should explore ways to facilitate obstetrician/gynecologists' use of the 5As method.
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Affiliation(s)
- Timothy R Jordan
- Department of Public Health, University of Toledo, Toledo, Ohio 43606, USA.
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Price JH, Jordan TR, Dake JA. Obstetricians and gynecologists’ perceptions and use of nicotine replacement therapy. J Community Health 2006; 31:160-75. [PMID: 16830505 DOI: 10.1007/s10900-005-9009-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this study was to assess Ohio obstetricians/ gynecologists' perceptions and use of nicotine replacement therapy (NRT) with pregnant smokers. A three-wave mailing procedure was used and 154 responded (44%) to a valid and reliable 36-item questionnaire regarding: Stage of Change in using NRT, perceptions of prescribing NRT, confidence in using NRT, barriers to prescribing NRT, and use of 5 A's counseling steps. One-fourth (26%) prescribed NRT to pregnant smokers. One-third (32%) perceived NRT as safe, yet few (14%) perceived it as effective. Respondents were most likely to prescribe NRT if the patient requested it (44%). Those most likely to prescribe NRT were more likely to: perceive use of NRT in pregnancy as safe (OR = 20.0); perceive NRT as effective in pregnancy (OR = 4.3); have high confidence in their ability to effectively prescribe NRT (OR = 3.86); and believed most or some of their colleagues prescribed NRT to pregnant smokers (OR = 6.7). The majority did not prescribe NRT possibly because few respondents received cigarette smoking cessation training in medical school or their residencies. Significant revisions in professional training and more continuing medical education are needed regarding smoking cessation and use of NRT.
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Affiliation(s)
- James H Price
- University of Toledo, Department of Public Health, Toledo, OH 43606, USA.
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18
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Heilbronner C, Berlin I. [Nicotine replacement therapies during pregnancy: what do we know about the balance between benefits and risks?]. ACTA ACUST UNITED AC 2005; 34:679-86. [PMID: 16270006 DOI: 10.1016/s0368-2315(05)82901-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Maternal smoking during pregnancy induces obstetrical and fetal complications but also has an impact on newborns, infants, children and adults. Nicotine replacement therapies are authorized during pregnancy in France, the purpose being to reduce fetal exposure to toxic compounds in tobacco smoke. However, it is not proven that nicotine replacement therapy is harmless to the fetus and to date, no study has demonstrated any beneficial effect in terms of abstinence. It is suggested that benefit and risks of nicotine replacement therapies during pregnancy should be evaluated.
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Affiliation(s)
- C Heilbronner
- Service de Pharmacologie, Groupe Hospitalier Universitaire Pitié-Salpêtrière, Paris
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Quelles sont les interventions efficaces d’aide à l’arrêt du tabac chez la femme enceinte ? ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s0368-2315(05)82985-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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20
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Lepage M, Dumas L, Renaud L. Lutter contre le tabac et promouvoir l'allaitement au Québec : un défi. SANTE PUBLIQUE 2005; 17:637-47. [PMID: 16485444 DOI: 10.3917/spub.054.0637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Quebec's breastfeeding rates are in a deplorable state, and even more so for smoking mothers. Public health providers are trying to increase breastfeeding rates and decrease smoking in this specific target group. Should they prioritise tobacco cessation interventions, or breastfeeding promotion interventions, or give equal priority to both goals at the same time? The authors attempt to scientifically answer this question, through a comprehensive literature review over the last ten years. In general, women who smoke have the tendency be younger, be less educated and more underprivileged than mothers who do not smoke and to breastfeed less often. Smoking mothers who do breastfeed usually wean off breastfeeding earlier than those who do not smoke. Pregnancy is considered an ideal moment to stop smoking, but relapse after giving birth is very high. In light of the range of difficulties faced when trying to quit smoking, health professionals should encourage smoking mothers to breastfeed since the benefits of breastfeeding could actually serve to reduce some of the harmful effects related to tobacco. Nicotine patches can be prescribed to increase the chances for successful tobacco cessation amongst these mothers. To date, few studies have been carried out on nicotine replacement therapies and breastfeeding smokers. More research is needed to evaluate the risks and benefits of nicotine substitutes for this sub-group, in both the short and long term.
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Affiliation(s)
- M Lepage
- Département des sciences infirmières, Université de Montréal et Université du Québec en Outaouais
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21
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Abstract
Smoking has been associated with several concerns in pregnancy including miscarriage, preterm delivery and stillbirth. Unfortunately, approximately 12% of the pregnant population continue to smoke cigarettes, suggesting a need for additional therapy beyond behavioural change. This paper reviews the literature on the use of nicotine replacement therapy and bupropion (Zyban®) in the pregnant human population, the pharmacokinetics of nicotine in the pregnant woman, and current guidelines for smoking cessation for pregnant patients. There are currently four studies that have investigated the use of nicotine patch, three for nicotine gum, and registry and preliminary reports for bupropion. These studies did not show any adverse pregnancy outcomes with the use of pharmacological aid for smoking cessation. All the nicotine replacement therapy studies, with the exception of one randomized-controlled nicotine patch trial had small sample sizes and looked at short-term use of drug in the third trimester. Two studies have examined the pharmacokinetics of nicotine in the pregnant woman. The results from these studies reveal greater nicotine metabolism in pregnant individuals who continue to smoke during pregnancy. Current guidelines from several organizations uniformly recommend that Nicotine Replacement Therapy should be considered if non-pharmacological therapies have been unsuccessful. Bupropion is recommended in pregnancy if the benefits outweigh the risks. There is a need for further studies on the safety and effectiveness of Nicotine Replacement therapy and bupropion in pregnancy. However, considering the current research and guidelines, pharmacological cessation aids should be considered if non-pharmacological therapies have not been effective.
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Affiliation(s)
- Bc Chan
- The Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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22
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Abstract
Smoking during pregnancy is a significant public health concern. Maternal smoking increases the risk of spontaneous abortion, low birth weight, premature delivery, sudden infant death syndrome and learning and behavioral problems in the offspring. Unfortunately, the majority of pregnant women do not quit smoking during pregnancy. Although pharmacotherapy may improve smoking cessation rates in pregnancy, very few studies exist that have studied the safety and efficacy of medications to treat pregnant smokers. This article reviews the available safety and efficacy data for the use in pregnancy of the five first-line therapies and two second-line therapies that are recommended for smoking cessation in non-pregnant smokers. Other promising nicotine replacement therapies are also reviewed. Ultimately, the choice whether to use pharmacotherapy for smoking cessation should be made jointly by the pregnant smoker and her health care provider. This article reviews factors that may be considered when prescribing pharmacotherapy to pregnant smokers (i.e. the role of behavioral counseling, identification of appropriate patients, potential advantages and disadvantages of each of the pharmacotherapies, proposed monitoring strategies, dose and duration and goals of treatment). More research regarding the safety and efficacy of pharmacotherapy during pregnancy is needed to define the risk/benefit profile of each medication for use in smoking cessation in pregnant women.
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Affiliation(s)
- C A Oncken
- Department of Medicine, University of Connecticut School of Medicine, Farmington 06030, USA.
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Moyer TP, Charlson JR, Enger RJ, Dale LC, Ebbert JO, Schroeder DR, Hurt RD. Simultaneous Analysis of Nicotine, Nicotine Metabolites, and Tobacco Alkaloids in Serum or Urine by Tandem Mass Spectrometry, with Clinically Relevant Metabolic Profiles. Clin Chem 2002. [DOI: 10.1093/clinchem/48.9.1460] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background: Assessment of nicotine metabolism and disposition has become an integral part of nicotine dependency treatment programs. Serum nicotine concentrations or urine cotinine concentrations can be used to guide nicotine patch dose to achieve biological concentrations adequate to provide the patient with immediate relief from nicotine withdrawal symptoms, an important factor in nicotine withdrawal success. Absence of nicotine metabolites and anabasine can be used to document abstinence from tobacco products, an indicator of treatment success.
Methods: The procedure was designed to quantify nicotine, cotinine, trans-3′-hydroxycotinine, anabasine, and nornicotine in human serum or urine. The technique required simple extraction of the sample with quantification by HPLC–tandem mass spectrometry.
Results: The procedure for simultaneous analysis of nicotine, its metabolites, and tobacco alkaloids simultaneously quantified five different analytes. Test limit of quantification, linearity, imprecision, and accuracy were adequate for clinical evaluation of patients undergoing treatment for tobacco dependency. The test readily distinguished individuals who had no exposure to tobacco products from individuals who were either passively exposed or were abstinent past-tobacco users from those who were actively using a tobacco or nicotine product.
Conclusions: Nicotine, cotinine, trans-3′-hydroxycotinine, nornicotine, and anabasine can be simultaneously and accurately quantified in either serum or urine by HPLC–tandem mass spectrometry with imprecision <10% at physiologic concentrations and limits of quantification ranging from 0.5 to 5 μg/L. Knowledge of serum or urine concentrations of these analytes can be used to guide nicotine replacement therapy or to assess tobacco abstinence in nicotine dependency treatment. These measurements are now an integral part of the clinical treatment and management of patients who wish to overcome tobacco dependence.
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Affiliation(s)
- Thomas P Moyer
- Drug Laboratory, Department of Laboratory Medicine & Pathology,
| | - Joel R Charlson
- Drug Laboratory, Department of Laboratory Medicine & Pathology,
| | - Robert J Enger
- Drug Laboratory, Department of Laboratory Medicine & Pathology,
| | - Lowell C Dale
- Nicotine Dependence Center, Department of Internal Medicine, and
| | - Jon O Ebbert
- Nicotine Dependence Center, Department of Internal Medicine, and
| | | | - Richard D Hurt
- Nicotine Dependence Center, Department of Internal Medicine, and
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