CEASE intervention enhances delivery of smoking cessation assistance for breastfeeding mothers

A study led by MassGeneral Hospital for Children (MGHfC) researchers demonstrates that an MGHfC-developed program designed to help the parents of pediatric patients quit smoking can increase the provision of such assistance to breastfeeding mothers. The report published online in Nicotine and Tobacco Research also provides information on how breastfeeding may affect whether or how much a mother currently is smoking.

"Mothers who smoke expose infants to secondhand and thirdhand smoke, and toxic substances can be transmitted through breast milk," says Jeremy Drehmer, MPH, CPH, of the MGHfC Division of General Academic Pediatrics and the Massachusetts General Hospital Tobacco Research and Treatment Center (TRTC), lead author of the report. "This is the first study to show that mothers who smoke while breastfeeding are not being provided evidence-based smoking cessation assistance when visiting their child's doctor. We found that 35 percent of mothers who have an infant 6 months old or younger and report ever smoking in their lifetime are continuing to smoke while breastfeeding. The study demonstrated that the CEASE intervention enhances the delivery of smoking cessation assistance at pediatric offices to mothers who breastfeed, capitalizing on this important time when mothers who smoke are more likely to quit."

Developed by a team led by Jonathan Winickoff, MD, MPH, of the MGHfC Division of General Academic Pediatrics, director of Pediatric Research in the MGH TRTC, the CEASE (Clinical Effort Against Secondhand Smoke Exposure) program trains pediatric office staff members to regularly ask patients' parents whether anyone smokes in their homes or cars and to provide assistance - nicotine replacement prescriptions and referrals to state quitlines - to household members who smoke. While studies have shown that mothers are more likely to quit smoking during pregnancy and while breastfeeding, most of those who smoked prior to pregnancy eventually resume. Although evidence has suggested that breastfeeding may be a critical time period to help mothers quit permanently, no previous study has investigated whether pediatric practices were providing smoking cessation assistance to breastfeeding mothers.

The current CEASE study was conducted at 10 pediatric practices - two each in the states of Ohio, Virginia, Tennessee, North Carolina and Indiana. At one practice in each state, staff members were trained in the CEASE intervention to screen patients' families for household tobacco use, advise parents on keeping their homes and cars smoke-free, and offer assistance to smoking family members in the form of nicotine replacement therapy prescriptions and enrollment in state-sponsored quitlines. The other practices in each state continued to offer usual care, serving as control practices.

The study period - April to October 2015 - began approximately two weeks after intervention practice staff had been trained in CEASE practices. During those six months, mothers of patients 1-year-old or younger were asked whether they had and were continuing to breastfeed that child, whether they had smoked at least 100 cigarettes in their lifetime, and for those who had, whether they had smoked at all in the preceding seven days. Two groups of mothers with a history of smoking - those who had smoked during the previous week and those who had quit at some time during the preceding two years, smoked at least one cigarette during that time but had not smoked during the previous week - were invited to enroll in the study.

Enrolled study participants were asked whether, during their child's clinical visit, a provider had asked if they smoked, advised them to quit smoking, given them a prescription for nicotine replacement therapy to help quit smoking and enrolled them in a telephone quitline. Of more than 2,000 mothers who had brought a child 1-year-old or younger in for pediatric care, 511 - 245 at intervention practices and 266 at control practices - were eligible for and participated in the enrollment interview.

Overall, among mothers who had ever smoked, those who were currently breastfeeding were less likely to currently be smoking than were those who had discontinued breastfeeding or had never breastfed. Currently smoking mothers who were breastfeeding were less likely to smoke every day and smoked fewer cigarettes per day than did those who had discontinued or had never breastfed. More than half of the breastfeeding mothers who currently smoked had tried to quit during the preceding three months, and among mothers who had smoked during the past year, those who were breastfeeding were more likely to have successfully quit during that time.

Responses to the enrollment interview revealed that mothers were more likely to have been asked about their smoking - 67 percent vs. 29 percent - and to have been advised to quit - 61 percent vs. 21 percent -at the CEASE practices than the control practices. While 50 percent of breastfeeding mothers who smoked received a nicotine replacement prescription and 28 percent were enrolled in telephone quitlines at the CEASE practices, none of those seen at control practices were offered those assistance methods.

"The findings that mothers with a history of smoking were less likely to smoke or smoked less while they were breastfeeding suggest that pairing smoking cessation assistance with breastfeeding is a strategic opportunity to help mothers quit for good, one that is drastically underutilized," says Drehmer. "We are continuing to develop the CEASE intervention and have partnered with several state health departments - most recently Indiana and North Carolina - to bring it to more practices around the country."

Senior author Winickoff, a professor of Pediatrics at Harvard Medical School, adds "Two-thirds of mothers who quit smoking during pregnancy will relapse in the first 6 months after birth. The CEASE intervention offers mothers a real lifeline to creating a smoke-free family. We hope that other states will consider adopting this program."

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