Reducing smoking and vaping in pregnancy
Jasmine
Thank you everyone. Welcome to this evening's webinar, Reducing smoking and vaping in pregnancy. My name is Jasmine and I will be your RACGP representative for this evening. Tonight, we are joined by our presenters, Dr Justine Daly and Professor Rowena Ivers who is also our GP facilitator for this webinar. Before we get started, I would like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders, past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening. I would like to introduce you to our speakers for this evening. Professor Rowena Ivers is a general practice academic based at the University of Wollongong. She has worked for over 30 years as a GP and has been involved in research in tobacco control, alcohol and nutrition as well as cancer prevention, including in the area of Aboriginal health. She currently serves on the RACGP National Research and Evaluation Ethics Committee. Next, we have Dr Justine Daly. She is a Program Manager at Hunter New England Population Health and a conjoint senior lecturer at the University of Newcastle. With over 25 years of experience as a population health researcher and practitioner, the primary focus of Justine's work has been working in partnership with Clinical Services to support the translation of evidence-based preventative care into routine service delivery, with a particular focus on smoking cessation interventions. Thank you to Rowena and Justine. I will hand this over now to Rowena to go through the learning objectives for tonight's session.
Professor Rowena Ivers
Thank you, Jasmine. So really today we are going to be talking about the landscape of smoking and vaping, and how that affects pregnant women and their babies, but especially an update on legislation and policy, but also really work on some skills in assessing dependence and look at this in pregnant women, but also looking at some communication strategies when talking to women about smoking and vaping cessation and really think about the evidence for these kind of interventions as well. Thank you, Justine.
Dr Justine Daly
Thank you, Rowena. We are just going to now have a little examine of the current landscape of smoking and vaping in pregnancy, specifically having a look at prevalence data and also the evidence so far on what we know about health risks. Just before we do have a look at this, I just wanted to touch on some key points in relation to addressing smoking and vaping during pregnancy that are important to keep in mind. Firstly, pregnancy does present a unique opportunity to address smoking and vaping because women are motivated to make changes for the health of their baby, and also the frequency of contact with antenatal care providers means that it is a really great opportunity to support someone through a smoking cessation journey. It is a really opportune time during antenatal care. Secondly, we know there has been a lot of research in this area that over two-thirds of pregnant women who smoke want to quit smoking, and they are often making multiple attempts to do so during pregnancy, and whilst quitting prior to or early in pregnancy is best, quitting at any time during pregnancy can result in reductions in risk and provide health benefits to both mother and baby. If a woman is not necessarily interested in quitting initially, it can be overwhelming perhaps in those early stages of pregnancy, it is important to continue to check in with them. Things might change throughout pregnancy because there will always be benefits for them quitting at any time. Just keep up that checking in, I guess is an important message, and finally, it is important to recognise that women will metabolise nicotine faster during pregnancy which can result in them feeling that they may want to smoke more, and they may therefore need extra support to quit smoking while pregnant. Let us have a look at some stats for smoking in pregnancy at the moment. According to national data from the Australian Institute of Health and Welfare, currently between 10% to 14% of women of childbearing age, that is between about 15 and 44 years smoke tobacco, and although some of these women will spontaneously quit upon finding out that they are pregnant, up to 60% of these women will continue to smoke. Encouragingly, rates of smoking during pregnancy have been gradually declining. In 2011, 13% of women reported smoking at some time during pregnancy, and the latest data indicates that about 8% of pregnant women currently smoke. However, these lower rates of smoking are not the reality for all members of the community, with rates being disproportionately higher among some groups. Specifically, 33% of women who live in remote areas report smoking during pregnancy, 18% of women living in the most disadvantaged postcodes, 31% of pregnant teenagers report smoking during pregnancy, 95% of pregnant women who are in alcohol and other drug treatment services, and 40% of Aboriginal and Torres Strait Islander women. It is important to note that smoking rates amongst Aboriginal and Torres Strait Islander women have decreased from 51% in 2010, and to also acknowledge that these higher smoking rates do exist within a complex historical context of colonisation, racism and socioeconomic disadvantage. Smoking does remain one of the most important preventable risk factors for pregnancy complications and poor outcomes for both mother and baby, and in fact, there is a 71% increased risk of infant mortality due to smoking and impacts extend to childhood and adulthood. Cigarette smoke contains over 7000 hazardous chemicals including nicotine, carbon monoxide, tar, benzene, heavy metals and many of these do cross the placenta and enter the foetal circulation. Known pregnancy complications include significantly increased risk of miscarriage, ectopic pregnancy, premature rupture of membranes, placenta previa, and abruption. Poor perinatal outcomes include significantly increased risk of low birth weight, stillbirth, small for gestational age, preterm birth, foetal growth restriction, cleft lip and palate. In the postnatal period, babies of mothers who smoke during pregnancy are at greater risk of SIDS, respiratory conditions, nicotine dependence, behavioural disorders, later in childhood, cognitive impairment issues with lactation and links to overweight and obesity later on in life. What do we know about the prevalence of vaping at the moment? Currently there is no national data that describes how many Australian women are vaping during pregnancy. What we can have a look at is we do know that in 22 to 23, around half of people aged 18 to 24 reported having ever used e-cigarettes at least once in their lifetime, and this was almost double the 26% of people who had done so in 2019. We are seeing huge increases in the use generally in young people of vapes. Population surveys from New South Wales, conducted in 2022/23, found that the prevalence of vaping in females of child bearing age ranged from 6% in the 35 to 44-year-old age bracket, up to 18% in the 16 to 24 year olds, and it is likely that these rates have increased since 2023. A 2022 study of over 4000 pregnant women who attended public antenatal clinics in the Hunter New England Local Health District found that just over 1% of pregnant women reported that they were currently using vapes, and concerningly, over a third of the current vapers reported dual use of cigarettes, so they were switching between vapes and cigarettes. When they were asked what their primary reasons were for vaping, they reported that they were using vapes to actually help them quit tobacco. These data suggest that we can expect that the use of vapes in pregnancy is likely to be more common now and you may be seeing this in your clinics. Let us unpack what we currently know about the risks of using vapes during pregnancy. We need to keep in mind that this is a rapidly evolving area of research, and we are unlikely to understand the long-term impacts of vaping on child health and development and chronic conditions until enough time has passed for the evidence to accumulate. I suppose as similar as we saw with the data for smoking and the risks associated with that and also second-hand smoke. What we do know, however, is that the majority of vapes contain nicotine. Laboratory testing of seized vapes products has found that most products illegally contain nicotine, often in high concentration, and this is regardless of labelling. A lot of these vapes actually do not say that they contain nicotine, but it has been found that the majority do. Vapes contain toxins, heavy metals, very fine particles that can cause adverse health effects. They have also been found to contain chemicals including formaldehyde, acrolein, mercury, arsenic and benzene. Most vapes on the market average around 10,000 puffs, and this is the nicotine equivalent of over 600 cigarettes. Evidence from systematic reviews indicate impacts on the mother's health will include development of nicotine dependency and an increased risk of nicotine poisoning and toxicity and other harms include throat irritation, coughs, headaches, nausea, and lung damage. Emerging evidence suggests that there may be some cardiovascular and respiratory health effects also. We know that nicotine from a vape does pass easily from the mother to the baby via the placenta in the same way as when tobacco is smoked. An exposure of the foetus to nicotine from vaping may be associated with preterm birth, low birth weight, small for gestational age, and perinatal death. Really, the take home message is that vaping is not safe in pregnancy, and there is currently no evidence that vapes can support smoking cessation in pregnancy. I will just hand over to Rowena now.
Professor Rowena Ivers
Thank you, Justine. Look at the exciting news. There is quite a few public health interventions that are making a difference in both the tobacco space and as well the vaping space, and as general practitioners and as part of the RACGP, we have been involved in that. Typically, there are GP policy experts who will look at and comment on some of these policies as they come in. Coming in this year, mid-July, certainly more restrictions around the flavours in tobacco, getting rid of menthol flavouring, and it is also restrictions on things like the marketing around what descriptions are given about cigarettes, but it is also reduced size of packs because there have been very large packs available, and the limitations even on roll your own, but specialised filters will be banned and then the warnings will also be updated. Vaping reforms again certainly in the expert advisory committee tobacco, we looked at all the evidence around vaping as part of a revision of the smoking guidelines, and really looking at and looked at smoked vaping for cessation of smoking, but really a lot of this is about we knew that a lot of people were taking up vaping without ever smoking. Really now in the new legislation, you can only really obtain vapes in a therapeutic pathway for management of nicotine dependence, and basically that is through a pharmacy or through a GP or other prescriber. The limitation on the flavours had quite an effect. The only flavours allowable now in mint, menthol and tobacco flavour. Basically, if you are over 18 you can buy a vape from a pharmacy as long as it is under 20 mg per ml without a prescription, and certainly, the higher dose vapes, you would need a prescription from a prescriber, a GP or other prescriber. For 18-year-old, you would always need a prescription, and yeah, it is worth having a look at the TGA vaping hub. That is meaning some of the tobacco strategies aims. It is trying to get to less than 10% by this year, but there is getting down to 5% is harder. In other countries, things like age limitation bans like New Zealand introduced have been tried, but we have also got to focus on smoking rates within women as well. Certainly for GPs, we definitely play a role. Primary care nurses play a role. I work in Aboriginal and Aboriginal health practitioners play a role, but really talking about smoking and vaping, it is something that all health professionals can do. I think before women fall pregnant is one of the most important things that you can do to address outcomes, and we know that smoking cessation before pregnancy or during pregnancy is one of the main things that we can do. When you look at the evidence for all the other things we do during antenatal care, like weighing someone or checking a urine test or taking all the various blood tests, giving up smoking is the main thing that is going to improve outcomes and reduce expenditure on things like neonatal intensive care units, but we know as GPs, we provide antenatal care to over 90% of women. We do those first visits and then 28% of women throughout pregnancy, through shared care programmes or as GP obstetricians. We also need to communicate with the other clinicians that we are referring to whether they are midwifery services or obstetric services about smoking as well. We know that the majority of people who smoke during pregnancy, they want help with quitting, and of course as GPs, we see the majority of people in the population through the year. Again, we have had a really good look. This took quite a while of looking at some of the review. There is a one very big Cochrane review of 88 RCTs over 28,000 women, and looking at those interventions including behavioural interventions advice, counselling and feedback, it really makes a big difference, and then 2020 a systematic review of 11 RCTs, it was a review of nicotine replacement therapy, and it really does increase smoking cessation rates by up to 40%. These are the national guidelines that the RACGP develops. They are available online. They are linked into most health pathways. They are our main evidence-based guidelines and they are developed with a range of professionals involved. I would really encourage them. If you need to look up information, you can always refer back to these. Many women will end up being supported in New South Wales setting. Some of them will get all of their antenatal care or obstetric care within New South Wales settings and New South Wales Health also has strong smoking cessation programs and they have their own guide on managing nicotine dependence, and again, tools for supporting people as outpatients. They also obviously have guidelines for people when they are admitted to hospital as well, and advice on NRT, and one of the advantages of being in New South Wales health, sometimes the NRT, if the NRT is funded. I should actually say with the RACGP guidelines, we move from the five A's to the simpler AAH model. I personally find this easier to easy to remember, Ask, Advise, Help. I am now going to hand back over to Justine to talk about giving behavioural support.
Dr Justine Daly
Thanks, Rowena. What we are going to do now is have a look at how to apply the ask, advise, help model to smoking and vaping cessation. I think one of the good things that it is a brief model that you can work through quite quickly, but to also remember that if you can apply some effective communication techniques while using the model with pregnant patients, then you will improve the likelihood that the intervention will lead to some behaviour change. What do we mean by effective communication techniques? I think importantly smoking and vaping need to be addressed in a supportive, non-judgemental manner. Smoking is not a lifestyle choice. It is a substance addiction and it needs to be treated as such. There is a huge amount of shame attached to smoking in pregnancy, and as more becomes known about the risks of vaping, that shame I guess will be transferred to vaping in pregnancy. It is really important to help patients understand their addiction, which can empower them, therefore to make some changes to their behaviour for the health of their baby. For example, if a patient knows that there is a physiological reason for them feeling that they need to smoke more that is because they are metabolising nicotine at a faster rate. They may be more open to accepting some assistance to manage those cravings, and we know with work we have done with midwives, when they have shared that information with women, they really appreciate having that understanding and it helps them manage the guilt of the feeling that they need to be smoking more regularly. Another important part of that communication is using a strength-based language and framing things in a positive way, such as talking about the benefits of quitting smoking rather than the risks of smoking and what you may be doing to your baby by smoking. Perhaps frame it by being a non-smoker, these are the benefits for your baby, and again, this is a more empowering approach, and it gives some control back to the patient if they can make these changes, and then there is benefit for their baby. It is important to engage the patients in a collaborative conversation through seeking their understanding around what they already know, what the gaps in their knowledge might be, and this will allow you then to tailor the information that you provide so you can then start the plan from where the patient is at with their knowledge and understanding of risks and what might help them to quit. Invite the patient's views on where they are at with their quit journey, and use joint decision making when planning actions to support behaviour change. Asking them things about what do they think they might need? What might help them? What might be the first steps in making changes? And importantly, use open ended questions, show empathy. A lot of women continuing to smoke are probably have very complex things going on for them. There might be a few things that that might need addressing at the same time and ask permission before sharing information as well. We will just step through these stats now. Here are some suggestions, maybe about how you might like to broach or conversation starters perhaps. It is really important that smoking status is assessed for all women during preconception, during pregnancy and as well for postnatal visits due to the stigma that is attached to smoking, particularly during pregnancy, some women may not accurately disclose their smoking status, and there has been some work done that has shown that using multiple choice response options can actually improve the disclosure of smoking status during pregnancy, allowing rather than just saying do you smoke and only giving the yes/no option, perhaps giving people an opportunity to say they are still smoking but they have made changes to their smoking. You may get a more accurate disclosure using that multiple response option. It is important not to forget to ask about other forms of tobacco smoking, such as shisha smoking through water pipes, smoking cannabis or Yarndi, which is the Aboriginal term for cannabis, and just for information in New South Wales public maternity services and I believe many maternity services across the country, it is now part of routine care to offer all women carbon monoxide breast screening to support their smoking cessation care, and this is usually offered prior to asking about smoking status. A carbon monoxide reading is taken and then a conversation can be had around whether or not someone smokes or if someone smokes in the home. The next step in our ask model is actually to determine nicotine dependence. The majority of people who are continuing to smoke during pregnancy are more than likely going to be nicotine dependent. Assessment of nicotine dependence can help predict whether a person who smokes is likely to experience nicotine withdrawal on stopping smoking, and the intensity and type of support that they may need to assist them to quit. A quick assessment of nicotine dependence can be made simply by asking the person who smokes, how soon after waking up, do you have your first vape or cigarette? Or do you crave your first vape or cigarette? Sometimes busy mums want to have a cigarette in the first 30 minutes, but they actually do not get a chance to, but when do they really feel like they need that first cigarette, and also a secondary question could be, have you had cravings for a cigarette or urges to smoke and withdrawal symptoms when you have tried to quit previously or when you have gone without cigarettes? Smoking or vaping within 30 minutes of waking and a history of withdrawal symptoms in previous quit attempts are all indicators of nicotine dependence. Nicotine withdrawal symptoms are usually occurring within 24 hours of abrupt cessation or a reduction in smoking and includes things like irritability, frustration, anger, anxiety, difficulty concentrating, depressed mood, insomnia. They would be the things that you would be looking out for. There is also a link there to the Managing Nicotine Dependence Guide, which has some more in-depth nicotine dependence assessment tools if you are interested in looking at some of those. Then we would move on to the advice step, and this is the step where we would discuss with all pregnant patients who smoke the benefits. Using that positive framing, the benefits of quitting smoking for them and their baby and how you can assist them to quit. Using the effective communication techniques that we outlined earlier, this conversation could start with asking them what they already know about the benefits for them and their baby of quitting smoking, and then based on any gaps in their knowledge, ask if they mind that you share some more information with them, and framing those benefits so that it is clear that they can take action and have positive impacts for the health of their baby, and many smokers actually report that they have had their smoking status assessed. They have been advised to quit, but often they are not offered help. It is really important to be clear that it is part of your role as their doctor or antenatal care provider to support them in their quitting journey. It is also important to identify any recent quitters. We know that between 50% to 70% of women who quit just before pregnancy or during pregnancy will relapse. I is vitally important that we identify them and offer them support if needed. It is a particularly vulnerable time also in that postnatal period, ensure to check in with new mums that were smokers prior to pregnancy or in early pregnancy to reinforce the importance and the benefits of them remaining non-smokers and offer any help that they may feel that they need, and there is just some examples there around how you might start that that conversation asking them what were their main reasons for quitting, reinforcing that those things are still really important to them and that you can help them.
Professor Rowena Ivers
The next part of our presentation is on the H phase, which is helping people to quit smoking, and as GPs we can give advice, but certainly it is about taking action, and many of these actions can be done by other practice staff as well. It is really providing self-help materials a lot of the time now with pamphlets. I actually text them a link rather than send them to give them a paper pamphlet. It is about that discussion about their barriers to smoking cessation, use the social support around them and offer cessation support for family members at the same time. If they are coming with their partner, their mother, if they are smokers, we do smoking cessation for everyone, and talk about the importance if there are family members who are still smoking about smoking outside if they are really rusted on. We do also use the Quitline. We have trained counsellors. There is also the Aboriginal Quitline and the counsellors who will follow up people, will have a follow up. There are also resources available in a number of languages or you can make an online referral as well. It is about those conversational tags. You can introduce these ideas to people as well in a non-judgemental way. Thinking about in pregnancy, it is a little bit different from non-pregnant people. Behavioural support has a very strong role, but in terms of pharmacotherapy, the first option always is intermittent NRT. That could be gum, it could be lozenges, it could be inhalers and it could be sprays, and often you will find that people have preferences about these. People sometimes have strong views about which one they prefer, and I have had a long conversation this week about the difference between all of these, and the nicotine is absorbed through the mouth. It probably more matches the nicotine pattern of smoking cigarettes. It is intermittent. The second line treatment, for example, if people are getting side effects like nausea or if they need a higher dose of NRT you can then use patches, and of course there is the different strengths of patches, but 21 mg is the standard patch, but the 7 and 14 are the other sizes as well. Again, talk to women about taking it off before they go to bed, but basically get up in the morning, have your shower, put on a patch. For people who really are heavy smokers or not tolerating or still getting withdrawal symptoms, you then can progress to a combination of NRTs like a patch and one of the intermittent versions as well. Again, it is about those conversational tags that you use to introduce this into the conversation. It really is about thinking about the risk of smoking compared to the risk of using nicotine in the form of these very well researched forms of nicotine. Obviously a lot of the oral forms, it is an oral route. You are not getting an effect on the lung. It is basically reducing the risk overall. Then flagging that it is good to use the patches if they do not want to use the NRT, and of course remembering that NRT is available over the counter as well and in some supermarkets. It is about giving people a bit of a guide to the accessibility for this. The nicotine patches are available on the PBS and on Close the Gap for Aboriginal patients as well.
Backing up that from the guidelines that it has an increased rate of cessation in pregnancy and then it is about that combination.
After pregnancy comes breastfeeding, and as a breastfeeding researcher, we need to think about what happens then. We know that smoking reduces breastfeeding rates. We know that nicotine also passes through breast milk. At the same time, having nicotine through NRT is less harmful than continued smoking. We know that for breastfeeding, women's clothes will smell of smoke, and that might be one of the things that has an impact as well. Again, it might be worth letting women know that they can use the intermittent NRT immediately after breastfeeding. It is about still continuing to provide those strategies to quit after they have had their baby as well, as well as all the measures to people smoking outside, not smoking around the baby as well. This is the standard table from the RACGP guidelines. Again, having a think about how many smokes people have a day and also how addicted they are. I still use the Fagerstrom measure, which is a measure of addiction. If people are smoking within 30 minutes of waking up or we have all got patients who wake a couple of times during the night to have a smoke or a vape. If it means they smoke as soon as they get up, they are probably more addicted. Again, if you get to the patch stage, you might be going with a patch plus a 4 mg gum if they are smoking more than 10 a day. For someone who waits longer till later in the morning and have a smoke, it might be a lower dose of gum. Always start with intermittent therapies and then go to a patch and then go to the combination.
In other adults, there is a range of other medications we use, the varenicline, the Champix and bupropion and even things like nortriptyline. There is a range of medications that are being used, however, not recommended in pregnant women. Again, getting back that our recommendation is not to use vapes in smoking cessation for pregnant people. They are not approved by the TGA. We do not know what the ingredients are. We have a unit here at University of Wollongong that looks at what is in them all. They come from a range of manufacturers. We really do not know whether the labelling when it has been tested is not necessarily correct. It is about really highlighting and having a conversation with women about the risks of vaping. Just letting them know we cannot use it for cessation. When women come to us and they are already vaping, we need to think about ways to cease vaping as well. Communicating the health effects of vaping while they are pregnant. There is a range of risks that we have already covered there. Certainly, it is not appropriate to prescribe vapes for pregnant people as well. If you are prescribing it to any smokers, you should check that they do a pregnancy check at the same time.
We have had a question arise here about giving support to people who are vaping and remembering that some of them will be smoking and vaping. Again, for both, it is good to again come back to behavioural advice, behavioural support, so that could mean people who are only intermittent vapers who maybe have a vape with their friend at a party or it might be appropriate to even stop cold turkey. For some people, if they are only vaping a little bit, it might be about weaning down. Basically, the heavier vapers might require NRT. Starting with and basically thinking about adjusting the dose trying to align the dose of what they are vaping to NRT. It would start with intermittent, thinking about patches, thinking about combination. I have put the image of one of the vaping devices here because probably the most common place I see vapes is thrown out on the road. It is actually great, if women have a vape, to actually get it out and have a look at it if it has got an ingredient list on it. Look at if you can match it to a commercial product to consider how much nicotine it might contain.
The problem with the vapes is that they are basically unregulated. From my experience, there still appears to be a lot of vapes on sale illegally through non-pharmacy locations and from a range of locations. We know from the testing of these vapes that there is huge variability in the nicotine that is available. We know that there is nicotine even in only fruit flavoured vapes that were available in the past. The amount can vary a lot, and again it is about the volume of nicotine in it and the number of puffs, as Justine alluded to. We know that with some smokers, when they transferred to vaping, they were actually having 700% more nicotine than what they were getting as smokers. Nicotine per cigarette 0.5 to 1.5, bit of variability as well. It is similar in terms of the liquid nicotine concentrations of up to 20 mg/mL, but knowing that many people were having much more than that. Basically it is about thinking which product are they using? Is it a prefilled pod or is it liquid that they are putting into their vape. In the past pathway, people were allowed to use personal importation route, which is now closed, and they could order vapes from overseas. There were many, many products that were available. Think about the dose of nicotine. Understanding the labelling may not be correct, and ask about how often they are vaping and how long is a vape lasting them as well. What I have done is look online for product guide or ask if it is a product they have bought from a pharmacist. You can actually find out the pharmacist to check that the dosing within that. A little bit complicated, but make an estimate of the milligrams or the equivalent cigarette number. Here is a resource from University of Wollongong colleagues who have done a lot of work on assessing vapes. This is a table here which is for when they are recommending going from for smokers using vapes for cessation and looking at the comparable, and again for this, we would actually be going with the vape dose and going back to a comparable cigarette dose to think about how you align what NRT they use.
It is about following up with people, and certainly in the clinic where I work, we have an Aboriginal health practitioner and other staff. Nursing items follow on from if they have a chronic disease or they have had an Aboriginal health check, you can actually use the follow on billing items for other staff to follow them up as well. When people are being transferred to other sources of antenatal care, for example, hospital antenatal clinic, private obstetrician, midwifery led clinic, it is about communicating to those teams about their smoking within your referrals as well. It is about touching base with those women. You can still touch base about their smoking as well.
Just to keep it interactive, we are going to give you a case study. This is probably a familiar story to many of you. A 28-year-old woman, first pregnancy, attends your clinic for a first antenatal check. She is already thinking about quitting smoking. She has smoked, but for a little while, while she has been trying for pregnant, she has been using nicotine vapes to quit smoking. She is using an enclosed pod, 20 mg/mL, it is about 15 mL, using one pod per day, and roughly equivalent of 15 cigarettes per day. I may have made an error with the calculation there. Anyway, thinking about next what are your options. Now we are going to put a poll up now to help her quit vapes. Okay. So the options are reducing vaping over a month, NRT patch 21 mg, NRT gum 2 mg, 10 to 12 per day, varenicline that is the Champix and NRT patches or apple flavoured vapes. If you want to choose an option and we will put it up on the screen. We have got some responses reducing vaping over a month, and we have got reducing vaping 23%, NRT patch 23%, NRT gum 53% and correctly everyone has not chosen the last two options. It is also a patient centred approach. You will find that many women will have quite strong views about what they want to do as well. It is about giving them some options. We are assuming we have already given a strong and targeted and personal but supportive advice about the risks and the benefits of quitting vaping. There are some women who will not engage and who will not want to use NRT despite we know there is an increased benefit from that. For them, reducing vaping or stopping vaping, if that is the only option they are going to choose, that is the right option for them. For them, again, I probably would start with NRT gum myself, and then if that was not successful, to go to NRT patch and again you can go to the combination. A little bit of that is monitored by thinking okay, does she get up in the middle of the night to vape. Does she get up first thing in the morning and have a vape? Then you might actually be using a stronger dose, like 21 mg and a 4 mg of gum. Thank you.
We will go to the next case study. Quiz time. I think Jasmine is putting up the questions here.
Jasmine
We have got a couple of questions on this one. We have a 23-year-old woman and her partner coming to your clinic to discuss preconception health, permission to talk about smoking and vaping and use AAH. Is your partner's smoking and vaping behaviours important and if they both smoke vape or are dual users indicate below how you would progress with supporting them to quit? Well, lots of responses coming through. I like this.
We have got some answers coming through. Just give it a moment. Okay, I will stop this one now. There we go.
Professor Rowena Ivers
Great. Okay. Question 1, 23-year-old woman coming to discuss preconception health. Yes. The most people saying you can talk about it and preconception health is a perfect time to talk about this for the partner and the mother as well. Good opportunity to talk about smoking pot as well because we know that affects sperm as well. Is the partner's smoking and vaping behaviours important? Absolutely with 98% and it is a great opportunity if you can catch them. Some partners will not engage. Some partners do not attend the appointments. Sometimes you do not have an opportunity to talk to them about it.
If both smoke vape or dual users, indicate below how you would progress with them supporting them to quit. Probably the majority said asking how they understand about smoking and vaping affects their baby. Then we have got a range of other responses there. Thank you, Jasmine. I wonder if we go to some of the questions from the floor now, shall we?
We have answered about how to get them off vapes. I do find that getting them off vapes, for me it is that calculating the dose and trying to work out how much they are actually using. In the end, it is about getting an approximation and trying to adjust their withdrawal symptoms to a dose of NRT. It is not an accurate science because we do not know where the products are coming from. We do not know what is in them a lot of the time. We do not know how much they are actually vaping. Certainly, studies show that when people are vaping, they were actually getting a lot more nicotine than they thought themselves they were getting. A few questions about Smokerlyser. I have used Smokerlyser myself as part of research trials and New South Wales health clinics will often have a Smokerlyser as well, but does not work for vaping. It also does not work for intermittent smokers. Certainly, in my research, we will look at people who would smoke pack a day, two packs a day on payday. Would not smoke in those last couple of days before they got paid. If you did Smokerlyser, that gave them a zero reading when they were not smoking. That is like thumbs up. I am smoking. This is great. It can falsely reassure people. It has a few risks. In terms of buying, some clinics do have them, some general practice clinics have purchased them. It is worth keeping a stock of other kind of smoking cessation resources. It gets helpful links that you can SMS, pop it to them in your SMS system with the electronic medical record system. Dr Wafa Kobeissi has got a question about association between nicotine and autism. Actually, I conveniently just looked this up. There is a couple of meta analyses, and the first meta analysis did not show any link for women smoking and their offspring having autism or was a bit of a trend, but it was not significant. Interestingly, yes, for dads smoking and exposure to second-hand smoke. There might be other factors going on there anyway. About the dosage of NRT, hopefully, we have addressed that. One more from Dr Wafa Kobeissi, can I legally decline prescribing vape to patients who state they need it to aid them quit smoking? I have had this discussion a number of times with GPs and non-GP specialists. We are not prescribing vapes during pregnancy so absolutely not during pregnancy. For non-pregnant adults, do a pregnancy test. You yourself can make a decision about that for both under 18s and over 18s. Many GPs are aware of the additional legal risks. For me, it is probably rare. I find that many people have not actually legitimately used decent doses of NRT. They have not legitimately tried some of the other pharmacotherapies and they have not been properly followed up. I am actually finding very few people will get to the point where they have gone through all those options and may need to consider vapes. Saying that, there might be situations, situations I have come across perhaps people with chronic severe mental illness, perhaps an intellectual disability on top of that, in a group home. On the balance of things, if they really have genuinely tried all the other options, vaping may be the best option. Then, it is a long discussion about the risks versus the benefits. I have actually got someone to sign a written consent when I was concerned about their understanding of the risks, but you absolutely can decline if that is your preference. I would continue to offer them all the genuine support for smoking as well.
A question from Dr Ferdinand Saldevar. Could HRT be used for cannabis use. I actually am not sure about the research on that area.
Dr Justine Daly
It would only be if they were mixing tobacco with cannabis.
Professor Rowena Ivers
I read the question as HRT.
Dr Justine Daly
I think it is meant to be NRT.
Professor Rowena Ivers
I am from Wollongong, the home of cannabis. I rarely meet someone who does not mix nicotine with their cannabis. Nicotine is much more addictive than cannabis. When people are asking for support in coming off cannabis, nicotine replacement therapy is absolutely the way to go. It is definitely recommended. I did literature search a few years ago to look at actually researching in using NRT for coming off cannabis. I did not find any then. I am not sure whether there is any since then, but absolutely 100% recommend it.
Vapes as a harm minimisation tool in nonpregnant people. Again, I think that the last case I mentioned, I can imagine that you could get to situations where someone who really has tried behavioural support, NRT, bupropion, varenicline are getting constant support about smoking cessation. In the end, as long as they are aware of the risks that we do not actually know the long-term risks of vape that may be less harmful to them to smoking cigarettes long term. We do not have the long-term follow up. I think that is all our questions. Thank you.
Jasmine
We do have one last poll for everybody, so I will just launch this one now. There is a couple of questions here. A pregnant woman has been seeing another GP in your practice and is booked for a visit with you. Her notes do not mention smoking or vaping in pregnancy. Do you assume she is not a smoker? Do you assess her smoking and vaping status? We have a pregnant woman is smoking and she is 14 weeks today. What advice would you give her about the benefits of quitting? There are a few answers that you can select from. It is also multiple choice. Then under the help model we have, are there other medications used to support smoking cessation. I am going to butcher the pronunciation of these, varenicline, bupropion indicated in pregnancy. Just get a few more answers and then we will stop this one.
Professor Rowena Ivers
There is some interesting discussion about whether the Ozempic will have an effect on smoking as well. Also, do not forget that Contrave which is an obesity tablet has bupropion in it.
We have got the responses now. The first question. Your colleague has not written notes. Basically assess her smoking and vaping status. You need to have that for accreditation as well. We are audited on that for when we have a practice accreditation. Number two, a pregnant woman is smoking at 14 weeks. How would you advice? I think there is not a one correct response here. Very popular, cutting down is a great way to start, but quitting completely is best for you and your baby. Next most popular is quitting before 20 weeks reduces the risk of stillbirth and having a small baby. This is sometimes difficult. I have certainly had a lot of women go, well, I will have a small baby. I will have an easier birth. A lot of women are actually not aware of the increased risk of stillbirth and premature labour and even SIDS after the baby is born. They are not aware of it at all. They have not thought about it, and again, some other responses there. Okay. Question three, yes. There are other medications used to support smoking cessation in pregnancy. The varenicline and bupropion are not recommended. They have not really been researched in pregnancy.
Jasmine
That is it, actually. All the content is done. I want to extend my thanks to Rowena and Justine for their time this evening to present their knowledge and expertise regarding this topic and also to everybody who attended this evening.