A Pharmacist's Role in Educating on the Health Risks of Smoking During Pregnancy and Helping Patients with Smoking Cessation

While many people know smoking causes cancer, heart disease and other major health problems, smoking during pregnancy causes additional fetal health complications including birth defects, premature birth and infant death. Cigarettes contain carbon monoxide and nicotine, both of which can cause a decrease in oxygen delivery to the fetus' developing tissues causing organs like the brain, lungs, kidneys and ears not to develop properly. If children are exposed to these toxins through secondhand smoke after birth, they are more likely to experience severe health problems such as ear infections, cataracts, lung cancer and heart disease. It is also ;known that nicotine is found in high concentrations in breast milk which allows it to be transferred to infants as they breastfeed. Approximately 15 to 20 percent of pregnant women smoke tobacco during pregnancy despite the strong :public-health campaign over the last few decades. Because of ithe risks and potential negative pregnancy outcomes, pharmacists have the duty to assess the patient's willingness to quit smoking (during and after pregnancy) and, if receptive, offer counseling and create a plan for cessation. Nonpharmacologic treatment is the best option for smoking cessation for ;women who are pregnant as it does not expose the fetus to 1any additional medications. The "S R's" are often used to in:fluence any patient, including pregnant women, to consider :quitting smoking and to provide them with the right direc;tion to successfully quit. Nonpharmacologic options are the most important for pregnant patients as pharmacologic treatments have not been studied sufficiently to determine ·safety for the fetus. Key Terms Breast Feeding; Carbon Monoxide; Fetus; Heart Disease; Nicotine; Parturition; Pharmacists; Pregnant Women; Premature Birth; Smoking; Smoking Cessation; Tobacco Introduction The contribution of the pharmacist is key in facilitating smoking cessation interventions in the community setting. Conveniently located in a retail setting, pharmacists are easily accessible to patients who seek counseling and follow-up consultation during smoking cessation. Pharmacists have a unique opportunity to counsel patients who are pregnant or are considering becoming pregnant on the risks of smoking during pregnancy as well as various treatment options for smoking cessation. Smoking during pregnancy can cause various health problems and risks for both the mother and the fetus including gestational bleeding, placental abruption, placenta previa miscarriage and preterm birth.1,2 Additionally, tobacco smoke contains many chemicals that are potentially toxic to fetal development. The most toxic include nicotine and carbon monoxide. Nonpharmacologic treatment using the "5 A's" counseling technique is considered first-line in order to prevent pregnancy complications and potential birth defects.3 Health Risks of Smoking During Pregnancy Numerous health risks of smoking during pregnancy exist. Many are linked to nicotine and carbon monoxide.1 Pharmacists can educate patients on the specific health risks linked to these chemicals. Specifically, nicotine has been shown to cross the placenta and enter fetal circulation in both active and passive smoking mothers resulting in an accumulation of nicotine in the fetal compartments as early as seven weeks gestation. The concentrations of nicotine in fetuses are known to be higher with longer lasting effects than the nicotine concentrations in the mothers. Evidence has shown nicotine concentrations are 15 percent higher in fetal circulation compared to the mother's, while the amniotic fluid contains nicotine concentrations that are 88 percent higher than those in the mother's plasma. These elevated concentrations of nicotine can cause vasoconstriction of the uteroplacental vasculature causing a decrease in the nutrients and oxygen reaching the fetus.2 Nicotine also causes alterations in cellular growth in the peripheral and central nervous systems of the fetus. Additionally, nicotine has been shown to suppress appetite which results in less maternal food intake and potential nutritional deprivation of the fetus. Ultimately, this causes a reduction in the energy supplied to the fetus which may deter its growth and development. Similarly, carbon monoxide has been shown to cross the placenta and bind to the hemoglobin in fetal circulation, displacing oxygen, which limits the delivery of oxygen to the tissues and organs of the fetus resulting in hypoxic ischemiaP The growth of the fetus during pregnancy depends on the oxygen and nutrition supply to help the tissues to continue to develop. Normally when fetal oxygen levels are low, a protective mechanism helps keep the brain supplied with oxygen. The chemicals from the cigarette can cause this protection mechanism to work incorrectly, reducing the exposure of the brain to oxygen, thus negatively impacting its growth and development. Specifically, the proposed mechanism is that nicotine increases the apoptosis of various structures in the brain including progenitor cells and postmitotic neurons.Considering the health concerns of carbon monoxide on fetal growth and development, research suggests that maternal smoking cessation early in pregnancy may support normal fetal head and brain and the prevention of volumetric changes associated with the brain including thinning of the frontal, parietal and temporal lobe which may take until adolescence to be manifested.1 Changes and abnormalities in brain structure 44 THE PHARMACY AND WELLNESS REVIEW Spring 2016 Volume 7, issue 2 ------·A-Ph•a•r•m•a•c•is.t's 111 R ! o•l•e•in•E•d•u•ca l'! t! 'l inllll! ' gllllo! "n•th"! "'"e•H•e•al•th-R•ls•k•s •of•S•m•o•k•in ! l g•D•u•r 111111 in1Pg•P•r•eg•n 111 a! ll n•cy•. •" -----Special Populations can cause long-term effects on behavior including an increased risk of Attention Deficient Hyperactivity Disorder (ADHD). U The fetuses of smoking mothers have an additionally increased risk of being born at a low birth weight, developing Sudden Infant Death Syndrome (SIDS) and being born with other respiratory diseases because nicotine exposure causes decreased airway size, resulting in a reduction in the overall growth of the lungs.2 The chemicals found in cigarettes may reduce kidney size leading to kidney malfunction later in life for the child.2 Newborns were shown to be four times more responsive to sound stimuli than their nonexposed counterparts resulting in potential dysfunction in their ability to process auditory information and potentially leading to both impaired reading and language skills as they grow up.1 Even though children exposed to cigarette smoking are initially smaller than those not exposed to prenatal smoking, they are at a higher risk for developing obesity later in life which puts them at risk for comorbid conditions like cardiovascular disease or diabetes.2 Additional Health Risks: Secondhand Smoke and Smoking During Breastfeeding Following pregnancy, some women choose to breastfeed their infant. However those who smoke tend to have a smaller milk supply and usually stop breastfeeding their infants sooner than those who do not smoke.4 It is known that nicotine can easily be transferred into the breast milk in high levels, and the amount of nicotine transferred to the breast milk is 2.9 times the amount present in the mother's blood plasma causing the infants to be exposed to nicotine every time they feed. This exposure to nicotine when feeding can cause shorter sleep times and altered sleep patterns especially if mothers smoke just prior to feeding their child.4,S A study by Primo and colleagues demonstrated that when mothers smoked before breastfeeding their children only slept for 53.4 minutes whereas children whose mothers did not smoke before breastfeeding slept on average 84.5 minutes.s The infants who were exposed to nicotine when they breastfed experienced sleeping disorders. Additionally, the study showed if the mother smoked during pregnancy and lactation, the child had permanent destruction of the pancreatic 13 cells which caused them to have an impaired glucose tolerance. Based on the findings of these studies, it important that smoking mothers be counseled on all the harmful chemicals in tobacco smoke and their potential detrimental effects on pediatric health. While limited research is currently available on the impact of e-cigarettes, it is thought that e-cigarettes have similar risks to regular cigarettes because e-cigarettes still deliver the same level of nicotine to the mother. Furthermore, the nicotine is passed to the infant in the same way as from regular cigarettes. Pharmacists can also educate patients on the additional fetal health risks of exposure to secondhand smoke and smoking during breastfeeding. Secondhand smoke is defined as smoke from a cigarette, pipe or a cigar that is inhaled by people in close proximity to the person smoking.6 Secondhand smoke is known to be dangerous and can cause mild symptoms in children like a stuffy nose, headache, sore throat, eye irritation, tooth decay and hoarseness.7 These children can also experience more serious health problems like lung cancer, heart disease, cataracts, wheezing, coughing and ear infections. Studies show children who are exposed to secondhand smoke are more likely to become sick with diseases like the common cold, pneumonia or bronchitis and tend to be sick longer than normal which causes them to miss more school than children from nonsmoking families. If a child has preexisting asthma, secondhand smoke can trigger asthma attacks which may occur more frequently with an increased severity. If the asthma attack is severe enough, it could require hospitalization and may be life threatening for the child.7,s Children who grow up in smoking households are also more likely to become smokers themselves.7 Smoking During Pregnancy: Patient Perceptions and Demographics Considering the known fetal and maternal health risks from