The National Preconception Health + Health Care Initiative                                                                                     July 2018
Virtual Learning & Sharing

#CareTheyDeserve Tweet Chat - June 27th, 3-4pm ET. We'll be discussing inclusive preconception health care best practices for all young adults. This is a #WellnessWed bilingual chat. 

IM CoIIN "Universal" TA Webinar Series - 
Led by the DATA team (Abt Associates) and open to all CoIIN teams. For details, email Upcoming webinars: 

June 27th, 3:30-5pm ET - Systems Mapping for Beginners 
July 11th, 3:30-5pm ET - Quarterly IM CoIIN Update for Stakeholders & Fellow Champions
Tobacco Cessation & Education Resources in CoIIN States
A comprehensive tobacco initiative, Oklahoma's, Tobacco Stops with Me campaign seeks to educate about the impact and dangers of tobacco, improve access to tobacco-free spaces, and expose the tactics of big tobacco 
California has one of the most robust anti-tobacco campaigns in the nation.  
With comprehensive information on second
-hand tobacco exposure, e-cigarettes, youth exposure, health equity and tobacco, and more, Tobacco Free CA has a wealth of resources and materials. 
Delaw are residents can find state-specific information and support at Healthy Delaware,  including access to the Delaware Quitline and information about cigarettes, vaping, and other non-cigarette tobacco products.  
North Carolina has statewide resources available through QuitlineNC, as well as resource s geared towards providers who serve women of reproductive age available through You Quit, Two Quit.   
What About E-Cigarettes and Vaping?
Electronic nicotine delivery systems (ENDS), are battery-operated devices designed to deliver nicotine with flavorings and other chemicals in aerosol instead of smoke. ENDS come in many different shapes and sizes. ENDS are commonly known as e-cigarettes, e-hookah, vape pens or tank and mod systems. There are over 250 brands of ENDS on the market.
ENDS aerosol is NOT harmless water vapor  

ENDS aerosol contains nicotine, fine particulate matter, volatile organic compounds, heavy metals and other compounds whose acute and long-term impacts are unknown.  Exposure to 
second-hand ENDS aerosol should be avoided, especially by pregnant women, infants, children, and adolescents. The CDC has stated that air  containing ENDS aerosol is not clean or safe. 
ENDS are NOT an FDA-approved cessation method  
While some people report that they have quit smoking using ENDS, the US Preventive Services Task Force guidelines state that there is insufficient evidence to promote them for tobacco cessation, and the FDA has not approved them for this use. Many ENDS users 
become "dual users," continuing to smoke combustible tobacco while also using ENDS.  Studies have shown that experienced ENDS users alter the power of their devices and puff patterns to deliver nicotine at similar levels to combustible tobacco.
ENDS are used by women across education and income levels
Combustible tobacco use is more common in populations with lower income, lower education, and those who live in rural areas. ENDS use 
among women is highest among suburban white women with more than a high school education.  
It is important to screen all women for all tobacco products, not just populations that have traditionally used combustible tobacco at higher rates 
ENDS are a poison control hazard
Liquid nicotine is extremely poisonous when ingested or makes contact with bare skin.  
Children are often drawn to e-liquids because they smell fruity or sweet and may be mistaken for candy. Even 1 teaspoon of liquid nicotine can 
be fatal for infants and young children and smaller amounts can cause severe illness.  It is important to counsel patients to call poison control - 1-800-222-1222 - if liquid nicotine has been ingested or in contact with skin.  
National Tobacco Cessation Resources is a good resource for people who want to quit using tobacco as well as for people who want to help someone in their lives stop. People need different resources as they try to quit smoking cigarettes and this site allows them to choose the help that best fits their needs. The information and professional assistance available on this web site and companion site Smokefree Women can help support immediate and long-term needs as people become, and remain, a non-smoker.

The North American Quitline Consortium is an international, non-profit membership organization that seeks to promote evidence-based Quitline services across diverse communities in North America. Quitlines are telephone- and web-based tobacco cessation services that help tobacco users quit. Today, residents in all 50 US states, Puerto Rico, Guam, and the District of Columbia have access to Quitline services. The NAQC Quitline Map provides information about state Quitlines and the services they provide.
Preconception Health Bi-weekly Updates
Sign up for the  CDC's bi-weekly updates on preconception and interconception health by  emailing Cheryl Robbins  ( A great resource for everything happening in the industry, across the country - and world!
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Big, Bad, and Trendy Tobacco
In spite of all the many risks associated with tobacco-use, it is still being marketed, produced, used, and advanced. Tobacco companies are not only increasing their reach, they are designing new products to expand their customer base, including liquid nicotine for vaping in appealing flavors and new, more discrete electronic products. For example, JUUL is a new product that looks like a USB stick, delivers significant doses of nicotine and has become very popular with teens. Click here for a video about this latest problem.

As health advocates, we need to not only stay current on the latest trends and their health impacts, we need to understand why women use tobacco. Some people may find it helps them cope with stress or manage their ADHD. Others may live with people who use tobacco and still others may use tobacco along with alcohol and other drugs to deal with the symptoms of trauma and/or pain in their lives. Helping people stop using tobacco takes patience, consistency, and empathy.

This month we are focusing on a critical women's preconception health intervention. Keep reading for information about tobacco cessation resources, campaigns, and CoIIN-specific state supports. 
Tobacco: Still Causing Harm for Women
Tobacco use damages almost every organ of the human body, leading to a multitude of diseases and reducing overall health and wellness. 
It is the single greatest  modifiable risk factor for preventable illness and premature death and is the leading cause  of death in women in the United States. 

Treating tobacco related illnesses costs billions of dollars each year.
The most current national BRFSS data (2016), reveals that 17.1% of women aged 18-44 are current smokers. This number is only based on cigarette smoking and greatly varies among states. 

Women who smoke double their risk for developing coronary heart disease and have a sixfold increased risk of heart attacks  compared to nonsmoking women. Smoking is directly responsible for more than 90% of chronic obstructive pulmonary disease (COPD), emphysema and chronic bronchitis deaths each year. The anti-estrogen effect of tobacco use accelerates menopause. This premature menopause increases the risk of cardiovascular disease and the risk of fracture independent of bone mineral density score. 
Smoking is directl y responsible for 80% of lung cancer deaths in women in the US each year. There is a linear relationship between pre-menopausal tobacco use and breast cancer, particularly if smoking is initiated before the birth of the first child.

Women who smoke are also at an increased risk of developing certain gynecologic cancers. Cigarette smoking has been identified as a risk factor in the development of ovarian cancer and contributes to the progression of cervical neoplasia. Women who smoke also have an increased risk for developing cancers of the mouth, esophagus, pancreas, kidney, bladder, and uterine cervix.
Tobacco use during pregnancy is a health risk for both the woman and the baby and remains one of the most preventable causes of pregnancy complications, illness and death among infants. Compared with nonsmokers, women who smoke before pregnancy are about twice as likely to experience delays in conception, infertility, ectopic pregnancy, miscarriage, premature rupture of the membranes, placental abruption, placenta previa, and stillbirth. Compared with babies born to non-smokers, infants exposed to tobacco during pregnancy are more likely to be premature, low birth weight, small for gestational age or fetal growth restricted, and born with a cleft lip, cleft palate, or both. They are also more likely to die of sudden infant death syndrome (SIDS), and suffer from respiratory conditions and childhood cancers.

From a life course perspective, tobacco use also increases the risk that the exposed fetus will become an adult with increased risk for obesity, hypertension, diabetes and tobacco addiction. CDC's Pregnancy Risk Assessment Monitoring System (PRAMS) data reports that 1 in 10 women smoke during the last three months of pregnancy. 
While quitting is hard, people who do so can begin to experience immediate health benefits. 

Given the intergenerational impact of tobacco use, addressing smoking is a critical preconception health and women's health intervention.
Evidence-Based, Best Practice Tobacco Cessation Screening and Counseling
 A large number of women who use tobacco want to quit, but they struggle with how to quit. 
The 5 As is a brief, evidence-based intervention that providers can use to help their patients quit smoking. 

The first A in this intervention is to ASK about (or screen for) tobacco use. This screening tool includes the use of validated tailored questions for prenatal, postpartum, and non-pregnant adults.   The use of multiple choice questions for screening, as opposed to a yes/ no question, greatly increases the disclosure of tobacco use. 

Click here to learn more about integrating clinically-based tobacco cessation programs.
Motivational In terviewing and Behavior Change Tools & Techniques 
The Cen tre for Collaboration, Motivation, and Innovation has a variety of useful tools to support motivatio nal interviewing and other techniques that facilitate behavior change.   Motivational Interviewing is a tested technique for guiding patients in the decision-making process to change their behavior. In this video, Connie Davis, RN, MN, ARNP, explains how Motivational Interviewing can be used to in practice.  

In "Ask, Tell, Ask", a provider first asks for permission or how much the patient wants to know, then shares the information clearly and concisely, then asks what the patient thinks of it or checks for understanding. 

Click here for a worksheet   that can be used to help patients consider the pros and cons of behavior change.