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1. Implementation/Conclusion
– Implement the change you are proposing- This should be a continuation of Part I and Part II
2. Describe the practice change; is it in the community, organizational, clinic setting and so forth
3. Discuss how you would implement and assess the change; this should include time frame, setting, participants, barriers, external and internal factors.
4. How would you evaluate the change process? 
-The change must be measurable
-How would you measure or evaluate? Is there a tool to measure?
5. The literature review must support your change and implementation. Use leadership qualities and skills that will be utilized for successful completion of the project.
6. Discuss who will be invited to the proposal: who are the stakeholders?
-How will you present the information to your ?1
The Application of Nicotine Replacement Therapy (NRT) by Smoking Pregnant
Maybelis Garcia
MSN Capstone Project
Professor: Carmen Lazo
Florida National University
When Pregnant Women Consider Nicotine Replacement Therapy Do They in
Comparison Opposed to Women who smoke during pregnancy to reduce The Dangers of
Childhood Health Concerns In The Future?
Reports show an increase in the nature of the alternatives to the smoking of tobacco
especially among pregnant women. They are linked to the lowered levels of harm that they
cause to the fetus after their birth and throughout their childhood. In this case, they are a great
representation of the high rates of harm associated with smoking during pregnancy hence the
major link to the harm caused by nicotine as a sole element in the products. They include low
birth weight, which creates a dire need to advise pregnant women to avoid certain lifestyles
drugs that include caffeine, nicotine and alcohol. However, it is difficult for the women who
use them to abstain leading to the continued smoking habit in around 8% of smoking women
in Europe and 6% in America according to Lange et al., (2018).The difference in the
exposure relationship is a strong suggestion that the use of smoke-free nicotine products that
include pharmaceutical nicotine products, electronic cigarettes that contain nicotine and
smokeless tobacco can be considered to have zero risk in relation to the risk from smoking.
The only problem is the level of lower risk that these choices in consumption have to help in
their establishment of viability as alternatives to use of nicotine during pregnancy to help in
the elimination of childhood health problems in the future.
When pregnant women apply nicotine replacement therapy do they as opposed to
smoking during pregnancy minimize the risk of childhood health concerns in the future?
In this case, they are the pregnant women subjected to many health risks from the
environment. These include smoke and nicotine from cigarettes.
There is a need to apply nicotine replacement therapy to mothers who smoke
The effects of the intervention will be compared to mothers who smoke cigarettes.
Therefore, it should act as an alternative.
The intervention is aimed at helping to lower the risk in fetus. They should be faced
with minimal growth challenges in childhood and in the future.
Most of the time, pregnant women are encouraged to quit smoking especially after
they get to know about their condition. This is because of the adverse effects that are
associated with nicotine on infants. There is a high chance that the harmful substances will be
passed on to fetuses that will experience numerous challenges. It is for this reason that current
treatment options in terms of alternatives that would guarantee safety and efficacy during
pregnancy are needed as indicated by Diamnati et al., 2019. There is sufficient evidence as
given through the significant and well documented hostile impacts of smoking during the
antenatal phase. They are recorded on both the mother and the fetus. Therefore, there are
recommendations towards the establishment of pharmacological measures that would help in
smoking cessation. Some of the common therapies used in this case include the application of
varenicline, sustained release bupropion and the NRT. Among these, the ones with decreased
levels of major malformations include bupropion and the therapy. This is an indication of
little evidence concerning the efficacy levels of vareniclines during pregnancy. In this case,
these agents are considered to only have limited success in the cessation of smoking. In this
case, it is important that the methods are used alongside behavioral counseling and education
to enhance the rates of quitting.
A lot of knowledge is presented concerning the risks of smoking during pregnancy. It
mainly presents danger to the population of pregnant women who already have a growing
fetus within them. These growing organisms depend on the parents for their nutrients and
thus are affected by the components smoked during the period to the extent that they suffer
from various forms of malformations as nicotine interferes with their growth and
development. It is known that cigarette smoke has numerous harmful compounds that are
well documented toxins and carcinogens, especially during the pregnancy period. It is for this
reason that there is a need to get alternative interventions for smoking mothers. It can be
applied through the application of nicotine replacement therapy or NRT that has been found
to have minimal to zero risks on the growth and formation of the developing fetus and is
similar to the cessation of smoking of tobacco during pregnancy. However, for effectiveness,
there has been a need to combine the therapy with some medications that portray enhanced
efficacy levels in the ability by the non-pregnant populations to stop their smoking habits
when compared to the standard NRT, which is the placebo.
Vulnerable Population
The vulnerable population in this case is the pregnant women. They experience
certain challenges in relation to the conditions in which the live and work that tend to affect
their health. This is not only an effect felt by the mothers but by extension to the developing
fetus that is affected by the lifestyle of the mother. In essence, the social determinants of
health that surround the mother affect the unborn child and thus greatly determine the
outcomes before and after birth (Gadelha et al., 2020). In this case, some of the lifestyle
behaviors such as smoking present risks to the pregnant women as they create a higher
chance for them to get pregnancy abnormalities. There is also the problem experienced when
a mother is under 17 years and above 35 years. Most of these affect the fetus that is exposed
to the harmful substances and thus affected since they are not able to undergo complete
development and thus go through numerous issues once they are born. In particular, smoking
during pregnancy has been associated with restriction of fetal growth and placenta prevue. It
is for this reason that an alternative measure that includes the use on nicotine replacement
therapy that has minimal risks rates becomes important.
Among the key health risk factors for pregnant mothers and the fetus whose growth
and development is affected is cigarette smoking. Infants who are exposed to tobacco and
nicotine in cigarettes feel the negative results before and after birth. It has an impact on their
growth and thus presents them with numerous health issues in the future. Therefore, there is a
need to help in cessation of the habit by the mothers through the use of behavioral therapy
and education to help in the reduction of the habit. Nonetheless, it is also possible to use
nicotine replacement therapy that has minimal risks when compared to tobacco use.
Theoretical Framework
Women who smoke before pregnancy tend to experience certain challenges while
trying to cease after they get pregnant. This is because of the associated behavioral planned
theory that bears various influences on individual behaviors as indicated by Flemming et al.,
(2016). Without proper interventions, there are bound to be numerous complications that lead
to high costs of healthcare. It may also lead to deformities on the fetus and cause future health
problems. Thus, the use of NRT alongside other interventions leads to a change in behavior
and the subsequent reduction of the dangers of health complications in infants born of
mothers who smoked during pregnancy.
Diamanti, A., Papadakis, S., Schoretsaniti, S., Rovina, N., Vivilaki, V., Gratziou, C., &
Katsaounou, P. A. (2019). Smoking cessation in pregnancy: An update for maternity
care practitioners. Tobacco induced diseases, 17.
Flemming, K., Graham, H., McCaughan, D., Angus, K., Sinclair, L., & Bauld, L. (2016).
Health professionals’ perceptions of the barriers and facilitators to providing smoking
cessation advice to women in pregnancy and during the post-partum period: a
systematic review of qualitative research. BMC Public Health, 16(1), 1-13.
Gadelha, I. P., Diniz, F. F., Aquino, P. D. S., Silva, D. D., Balsells, M. M. D., & Pinheiro, A.
K. B. (2020). Social determinants of health of high-risk pregnant women during
prenatal follow-up. Rev Rene, 21(1), 1-8.
Lange, S., Probst, C., Rehm, J., & Popova, S. (2018). National, regional, and global
prevalence of smoking during pregnancy in the general population: a systematic
review and meta-analysis. The Lancet Global Health, 6(7), e769-e776.
Review of Literature
Maybelis Garcia
Florida National University
Professor: Carmen Lazo
MSN Capstone Project
Review of Literature
Using search terms and truncated titles, the author identified ten articles on the health
implications of smoking and smoking cessation during pregnancy and during postpartum.
Among the keywords used to locate the articles include smoking during pregnancy, smoking,
postpartum, cessation, child defects, and community education.
Nicotine and Pregnancy
Smoking during pregnancy has been associated with various negative health implications
for the unborn. While the effects can vary based on the method of smoking, it is often advisable
that pregnant women shy away from nicotine. Jacob, Golmard, and Berlin (2016) conducted a
randomized control study to evaluate the impacts of nicotine constituents on birth defects. The
authors collected the sample from 42 women who agreed to participate in the study. The
outcomes indicated that regardless of the origin of nicotine, the fetus was exposed to the negative
health impacts of nicotine on the mother’s blood. They concluded that in general, nicotine
constituents have a positive relationship with birth defects if the mother was exposed to those
substances during pregnancy. Similar conclusions have been established in other studies. For
instance, in 2015, Dhalwani et al. reported on a pregnancy cohort from the Health Improvement
Network (THIN). The findings from the study indicated that although the level of severity
decreased based on the form of consumption, with NRT having reduced negative effects, one
undeniable observation was that nicotine use increases the risk of birth anomalies. Respiratory,
learning, and development anomalies are among the common adverse outcomes of smoking
during pregnancy. Both studies used larger sample sizes to test their hypotheses and arrive at the
conclusion. Measures need to be taken to encourage pregnant women to cease smoking for the
period as a means of improving the chances that the infants have not been placed at a high risk of
birth anomalies.
Education as an Intervention for Smoking Cessation Among Pregnant Women
Despite the dangers of smoking while pregnant, most women are still more likely to do
so. Especially, first-time mothers who deal with the stress and anxiety of having a baby are more
often smoking during pregnancy. Barakoti, Ghimire, Pandey, Baral, and Pokharel (2017)
conducted a cross-sectional study in Sankhuwasabha, a mountain district of eastern Nepal using
a representative sample of 436 women of reproductive age. The author aimed to discern the
factors that contribute to prenatal smoking. Based on the outcomes of the analysis, Barakoti
found that first, tobacco use is a major health problem that is claiming the lives of several people
across the world. Second, they argued that despite the opportunities for prevention, most people
often fail to consider the long-term risks of smoking tobacco. Last, among pregnant women,
tobacco use is associated with a wide array of factors, including illiteracy, the number of children
the mothers had, a history of alcohol consumption, and family members’ influence. Regardless,
the authors argued that there is a need for an intervention to promote cigarette caseation during
pregnancy because of the health implications it had on the mother and the unborn child.
Attitudes also play a role in the smoking behaviors of nonsmokers and smokers. In a
Jordanian study that included a sample of 436 pregnant women in the Governorate of Irbid,
Jordan, the results indicated that between smokers and nonsmokers, the perceptions about the
means of tobacco smoking determined the rate or risk of smoking among pregnant women
(Hamadneh et al., 2021). Smokers have positive attitudes toward the differences in the level of
impact of the smoking method compared to non-smokers. Nonsmokers consider all means
unhealthy, while smokers consider electronic and hookah as safer compared to cigarettes. Odibo,
Zamudio, Young, Magann, & Williams (2015) reported similar findings. The authors argued that
obstetrician-gynecologists should implement aggressive patient education on the dangers of
smoking during pregnancy. This is because the lack of adverse effects of smoking on birth
outcomes is a key driver towards the high rates of smoking among pregnant women. Patient
education increases their awareness and helps channel their attitudes towards healthier behaviors
such as smoking cessation.
During education, the choice of medium should also be strategic. Face-to-face education
is found to be more effective in persuading clients compared to other methods. For instance, the
use of telemedicine has been found to poke gaps in the ability to promote positive health
behavior because of the lack of contact and persuasive force. Clients who are educated based on
a face-to-face medium report substantially effective outcomes compared to those who attend
telemedicine conferences (Khayat et al., 2022). While each method has its cons and pros, the
most suitable one should be selected based on the context and resource availability
Alternatives to Smoking cessation during Pregnancy
Smoking cessation is a challenging task, especially if it is abrupt. Patients can suffer
withdrawals or negative outcomes in their quality of life due to depression and psychological
disturbances. As a result, some options have been established to counter the need for quitting
cigarettes during pregnancy. Among them is nicotine replacement therapy. Brose, McEwen &
West (2013) argued that although NRT has an 80% chance of limiting birth defects such as
attention deficit disorder, there are tradeoffs that compromise the overall positive effect it has on
fetal development (Blanc et al., 2021). In line with the same arguments, Hajek et al., (2019)
found that “Within the context of multisession treatment for smokers seeking help, e-cigarettes
were significantly more effective than NRT” (p. 1). That is because, pregnant smokers require a
larger amount of nicotine, which is compensated through high doses of NRT (Cooper et al.,
2014). The overall impacts are that the health risk factors are transferred through NRT. Ecigarettes are preferred because of the ingredients that protect vapers from airborne infections.
Additionally, the latter is more cost-effective compared to NRTs. Besides, population-based
participants are less likely to adhere to NRTs, which questions their reliance on and
appropriateness as alternatives to smoking cessation. This is in accordance with findings resented
by Mersha, Eftekhari, Bovill, Tollosa & Gould (2021). The authors conducted a systematic
review and meta-analysis was conducted using studies retrieved from five electronic databases
and grey literature.
Objectives for the Practice Change
The objective of the practice change is to enrich patient care interventions for pregnant
mothers in terms of addressing the gap between existing interventions and patient needs. The
goal is to achieve a middle ground between smoking and smoking cessation. Most smokers find
it very challenging to quit smoking, which creates another problem during pregnancy.
Summary of the Articles Reviewed
A larger number of the articles reviewed involved primary data collection and analysis of
the key points analyzed. That is why they are effective in arguing against or for the proposed
study, including the presenting barriers to the intervention implementation. However, one
limitation is that the errors in each study can culminate to compromise the overall impact of the
analysis because none has been addressed so far. It is necessary for future studies to also include
a control group of women with no exposure to nicotine.
Barakoti, R., Ghimire, A., Pandey, A. R., Baral, D. D., & Pokharel, P. K. (2017). Tobacco use
during pregnancy and its associated factors in a mountain district of Eastern Nepal: A
cross-sectional questionnaire survey. Frontiers in Public Health, 5.
Blanc, J., Tosello, B., Ekblad, M. O., Berlin, I., & Netter, A. (2021). Nicotine Replacement
Therapy during Pregnancy and Child Health Outcomes: A Systematic
Review. International journal of environmental research and public health, 18(8), 4004.
Brose, L. S., McEwen, A., & West, R. (2013). Association between nicotine replacement therapy
use in pregnancy and smoking cessation. Drug and alcohol dependence, 132(3), 660–
664. https://doi.org/10.1016/j.drugalcdep.2013.04.017
Cooper, S., Taggar, J., Lewis, S., Marlow, N., Dickinson, A., Whitemore, R., Coleman, T., &
Smoking, Nicotine and Pregnancy (SNAP) Trial Team (2014). Effect of nicotine patches
in pregnancy on infant and maternal outcomes at 2 years: follow-up from the randomised,
double-blind, placebo-controlled SNAP trial. The Lancet. Respiratory medicine, 2(9),
728–737. https://doi.org/10.1016/S2213-2600(14)70157-2
Hajek, P., Phillips-Waller, A., Przulj, D., Pesola, F., Smith, K. M., Bisal, N., Li, J., Parrott, S.,
Sasieni, P., Dawkins, L., Ross, L., Goniewicz, M., Wu, Q., & McRobbie, H. J. (2019). Ecigarettes compared with nicotine replacement therapy within the UK Stop Smoking
Services: the TEC RCT. Health technology assessment (Winchester, England), 23(43), 1–
82. https://doi.org/10.3310/hta23430
Hamadneh, J., Hamadneh, S., Amarin, Z., & Al-Beitawi, S. (2021). Knowledge, Attitude and
Smoking Patterns Among Pregnant Women: A Jordanian Perspective. Annals of global
health, 87(1), 36. https://doi.org/10.5334/aogh.3279
Jacob N, Golmard JL, Berlin I. Fetal exposure to tobacco: nicotine and cotinine concentration in
amniotic fluid and maternal saliva. J Matern Fetal Neonatal Med. 2017 Jan;30(2):233239. doi: 10.3109/14767058.2016.1169523. Epub 2016 Apr 19. PMID: 27001007.
Khayat, S., Palizvan, M., Navidian, A., Fanaei, H., & Sheikhi, Z. P. (2022). Comparison of the
effect of face-to-face training and telemedicine on self-care in adolescent pregnant
women: A quasi-experimental study. Journal of education and health promotion, 11,
326. https://doi.org/10.4103/jehp.jehp_1729_21
Mersha, A. G., Eftekhari, P., Bovill, M., Tollosa, D. N., & Gould, G. S. (2021). Evaluating level
of adherence to nicotine replacement therapy and its impact on Smoking Cessation: A
systematic review and meta-analysis. Archives of Public Health, 79(1).
Odibo, I. N., Zamudio, S., Young, J. M., Magann, E. F., & Williams, S. F. (2015). Patient
Awareness of Untoward Effects of Smoking on Fetal and Maternal Well-being During
Pregnancy: A Pilot Study. Journal of addiction medicine, 9(3), 211–216.

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