Addressing Tobacco And Secondhand Smoke Exposure In Maternal And Child Survival Programs

Ending preventable child and maternal deaths (EPCMD) by 2035 is one of US Agency for International Development's (USAID) three global health priorities, along with creating an AIDS-Free Generation and protecting communities from infectious diseases. In June 2014 USAID launched the report Acting on the Call: Ending Preventable Maternal and Child Deaths, which provides an evidence-based approach to meeting this goal across USAID's 24 EPCMD focus countries. One of the key elements of the EPCMD approach is alignment across interventions to meet the needs of affected populations; for this reason, Acting on the Call incorporates programs for maternal and child health, malaria, family planning, nutrition, HIV/AIDS and water, sanitation, and hygiene.

Enhancing efforts to prevent tobacco use and secondhand smoke (SHS) exposure would close a critical gap in this strategy. Six million people die from tobacco use and 600,000 from SHS each year, with nearly half of SHS deaths occurring among women and a quarter among children under the age of five. Prematurity, low birth weight, and other causes of death could be prevented by elimination of smoke exposure. Scalable, sustainable solutions exist to address this threat, and could contribute directly to improved maternal and child survival.

The Burden Of Secondhand Smoke

There is a wealth of evidence to illustrate the devastating impact SHS has on women and children. Children bear the greatest burden of years of life lost due to SHS, with 168,000 children having died from SHS in 2004 alone. Pregnant women exposed to SHS are 23 percent more likely to experience stillbirth and 13 percent more likely to have children with congenital malformations, in addition to their children's increased risks for low birth weight and Sudden Infant Death Syndrome.

SHS is also implicated in other adverse health outcomes, which can impact mortality. SHS suppresses the immune system and increases the burden of infectious diseases in children including for influenza, respiratory syncytial virus, tuberculosis, acute gastroenteritis, and pneumonia. The non-communicable disease burden is also high in children exposed to SHS, with increased risks for asthma, oral health problems, cancers, obesity, metabolic syndrome, cardiovascular diseases, and Type 1 diabetes.

Women And Children At Risk

Unfortunately, tobacco use and exposure is growing in many populations that are already burdened by high rates of preventable deaths. While smoking prevalence declined in a majority of countries during the last decade (2000-2010), rapid increases in tobacco use are predicted in Africa and the eastern Mediterranean, with several low-income and middle-income countries most at risk of worsening tobacco epidemics by 2025. Tobacco caused 100 million deaths during the 20th century and will claim 1 billion deaths in the 21st century if action is not taken. As cigarettes become more affordable in many countries, tobacco companies are targeting women by selling western women's lifestyles in ads.

For children, the primary source of SHS exposure is in a private home or a family vehicle. A useful snapshot of SHS exposure among a cohort of 13-15 year old students comes from the Global Youth Tobacco Survey (GYTS), a global surveillance initiative coordinated by the World Health Organization/Tobacco Free Initiative (WHO/TFI) and the U.S. Centers for Disease Control and Prevention/Office on Smoking and Health (CDC/OSH) from 1999 to 2001. Almost half of respondents in 44 countries and territories (48.9 percent) reported being exposed to SHS in their homes.

Opportunities And Recommendations

On August 27, 2015 the American Academy of Pediatrics (AAP) convened 22 experts from the U.S. government, private sector, and academia for an informal, off-the-record discussion about the relationship between tobacco/SHS and EPCMD. Participants identified a number of evidence-based interventions that could easily and practically be integrated into existing EPCMD platforms, such as Acting on the Call and the global Strategy. Significantly—and hearteningly—many of these interventions are already included in the WHO's "essential practice guide" to "Pregnancy, Childbirth, Postpartum and Newborn Care," the most recent edition of which was released in October. The interventions recommended include:

• All health care facilities should be smoke-free to protect the health of staff, patients, and visitors.
• Evidence-based clinical interventions can and should be adapted for use by all clinicians, including by frontline health workers.
• Health care professionals can help to disseminate information and change norms and behavior, including at a minimum by asking and advising about tobacco use and SHS.
• Health care professionals should ask all parents about smoking in the home and family and should make it a point to educate parents about the dangers of SHS.
• Clinicians should routinely offer advice and assistance to help tobacco users.
• Waiting rooms offer an opportunity to screen or provide health education, including through handouts, storyboards, posters, and signs that are both culturally and literacy-level appropriate.
• Tobacco/SHS messaging also should be integrated into standards for routine care.

Specific entry points exist throughout the continuum of care. Globally, about 80 percent of pregnant women make at least one antenatal care visit, although that figure varies by region. Partners who smoke often attend these antenatal visits, providing a critical opportunity to work with women's partners to explain the risks of SHS to both the woman and the unborn child.

• National and sub-national tobacco control strategies can be aligned with the WHO recommendations for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy.
• Clinicians should ask all pregnant women about tobacco use and exposure to SHS at every visit. They should offer pregnant women and their families advice and information about the risks of SHS, and they should offer cessation support.
• SHS guidance should be incorporated into essential newborn care delivery, as well as in all other newborn and childcare recommendations.
• Caregivers can discuss tobacco and SHS during immunization or other preventive service delivery visits and/or during infectious disease interventions.
• Tobacco/SHS messages should be part of adolescent health visits and family planning messaging. For adults and adolescents who smoke, clinicians should either offer cessation treatment or refer the patient to someone who offers those services.

For an example of the impact that simple, scalable interventions can make in the hands of indigenous health workers, we can look to Helping Babies Breathe, a low-literacy curriculum developed by the AAP. This curriculum has been introduced through newborn resuscitation programs that have trained more than 300,000 birth attendants in 77 countries since 2010. Over 50 of the programs are now coordinated by national governments. Studies in Tanzania and Nepal have shown early newborn mortality reductions of nearly 50 percent.

Existing Platforms For Integration

The recommendations are consistent with the MPOWER measures, introduced by the WHO in 2008 to assist in country-level implementation of the Framework Convention on Tobacco Control (FCTC). Crucially, they could be fairly easily implemented through existing U.S. government assistance partnerships and programs. These include:

• USAID's Maternal and Child Survival Program (MCSP), a global partnership to introduce and support high-impact health interventions with a focus on 24 high-priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation.
• Saving Lives at Birth: A Grand Challenge for Development, which receives support from USAID, the Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and the United Kingdom's Department for International Development to find innovative tools and approaches to save the lives of pregnant women and newborns in poor, hard-to-reach communities.
• The Survive and Thrive partnership, which engages U.S. pediatric, obstetrical, and midwifery membership organizations in collaboration with international and national professional associations to strengthen maternal, newborn, and child health programs.
• USAID's Partnerships for Enhanced Engagement in Research (PEER) program, which leverages research investments by U.S. government science agencies to improve development results in USAID-presence countries. Awards have been made in Indonesia to generate evidence on the relationship between prenatal exposure to household tobacco and preterm/low birth weight outcomes, and in the Philippines focused on the impact of tobacco use on childhood TB outcomes.

The Broader Policy Context

As discussed above, these recommendations are meant to highlight practical steps that can be taken by existing EPCMD programs. However, it is important to also note the broader public health and policy contexts in which these programs exist.

The global health community can learn from and align with other public health programs. For example, the Center for Disease Control's (CDC) Communities Putting Prevention to Work program and other, ongoing community and state-based technical assistance grants support capacity building in the United States to reduce obesity and tobacco use. These programs address both clinical and policy opportunities for improving health, and also help link state and local public health advocates.

According to The Cancer Atlas, a report of the American Cancer Society, the most widely implemented tobacco control policies are focused on demand reduction. Demand-side policies are designed to reduce tobacco use initiation (prevention) and/or increase cessation (intervention). The most effective demand-side policies are often found to be those focused on taxes and pricing. Additionally, cessation messaging that targets adult smokers with appropriate public health messages have consistently been shown to decrease the prevalence of smoking among youth.

The Bloomberg Initiative to Reduce Tobacco, part of Bloomberg Philanthropies, has demonstrated the impact of policy change and public awareness activities in the multiple countries with the highest prevalence and number of tobacco users. Funding supported activities such as creating smoke-free public places, banning tobacco advertising, increasing taxes on tobacco products, requiring graphic pack warnings, and conducting mass media campaigns. However, these investments have not in general addressed the relationship between maternal and child health outcomes and tobacco/SHS.

While the focus here is on SHS activities undertaken by USAID, ideally these would be amplified through a whole-of-government strategy that includes the CDC, the Department of State, and the Department of Commerce. SHS should also be part of the dialogue between the U.S. government and its EPCMD partners, including UNICEF and the World Health Organization's Partnership for Maternal, Newborn & Child Health, as they support country-owned efforts to fully realize the new Sustainable Development Goal to "Ensure healthy lives and promote well-being for all at all ages."

Building The Evidence Base And Moving Forward

There is much we still don't know, and operational research on SHS and tobacco in all forms can help to fill in those gaps. Some of these questions relate to which interventions work best, such as the relative efficacy of various tobacco control programs and curricula; the relative efficacy and practicality of alternative tobacco/SHS counseling and advising strategies by health care workers; comparisons of behavioral interventions for tobacco cessation during pregnancy; the impact of smoke-free zones around schools; and the safety, efficacy, and adherence of pharmacological cessation medications in low resource settings. Others relate to comorbidities and disease burdens, including tobacco/SHS impact on the health outcomes of TB and HIV.

SHS interventions can be included in the tools that experts already use. The integration of SHS control measures into the Johns Hopkins Bloomberg School's Lives Saved Tool (LiST), for example, could help stakeholders evaluate the potential impact of SHS interventions in their countries and districts. This would require improved data collection on a country-by-country basis.

While additional research can help refine the actions to be taken, there is no excuse not to act now. The evidence shows that USAID can advance its EPCMD goals by addressing tobacco and SHS, and tools and platforms already exist for implementers to support it in doing so. SHS should be part of the discussion about saving women's and children's lives.

from Health Affairs Blog http://ift.tt/1LxRKeI