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Family planning and the campaigns against smoking and obesitySpecial Analysis
factors for a large number of critical health problems,such as heart disease, stroke and cancer.
According to a 2001 surgeon general report on womenand smoking, three million U.S. women have died pre- maturely from smoking-related disease since 1980, andlung cancer is now the leading cause of female cancer death (surpassing breast cancer). Similarly, Satcher’s2001 report on obesity associated that condition with Efforts to reduce smoking and obesity have diabetes, heart disease, stroke, hypertension, cancer become high priorities for public health and a number of other problems. In an April 2002report by the Centers for Disease Control and advocates, provider groups and policymak- Prevention (CDC), researchers estimated that smoking ers. Both smoking and obesity have sub- cost $158 billion per year in the late 1990s, including stantial implications for reproductive medical care costs and productivity losses. Similar health, negatively affecting pregnancy out- numbers were cited by the surgeon general for obe-sity—$117 billion in 2000.
comes and fertility, and limiting women’scontraceptive choices. Reproductive health The impact of neither epidemic is likely to fade anytime providers have much to contribute to anti- soon. Incidence of smoking has declined significantly smoking and antiobesity public health among American adults, but the decline has slowedconsiderably, and rates are still dangerously high.
According to the National Center for Health Statistics(NCHS), the incidence of smoking has dropped from By Adam Sonfield
42% of adults in 1965, to 25% in 1990 and 23% in 2000.
Smoking among high school students peaked at 36% in In early April, a coalition led by the American Public Health Association celebrated National Public HealthWeek by raising awareness about the epidemic of over- In contrast to the smoking epidemic, obesity is a weight and obesity in the United States. The next rapidly increasing problem. NCHS reports that 31% of month, the Department of Health and Human Services U.S. adults were obese in 1999–2000, up from 13% in (DHHS) announced a new program of community 1960–1962 and 23% in 1988–1994. Although weight grants to prevent several chronic health conditions, problems are less common among children than among such as those caused by smoking and poor diet. And in adults, the proportion of children who are overweight June, Senate Majority Leader Bill Frist (R-TN), with has more than tripled since the 1960s. [Overweight for bipartisan support, introduced a bill—one of many adults is defined as body mass index (BMI) at or above similar measures introduced this session—that would 25; obese, at or above 30; age-specific standards are authorize new grants for obesity prevention.
used for children. BMI is defined as weight (in kilo-grams) divided by the square of height (in meters).] These efforts are examples of a growing awareness inthe United States about how lifestyle changes can posi- Rates of smoking and obesity are particularly high for tively impact public health. The antiobesity message, certain demographic groups, according to data from the while simmering for many years, has recently come to surgeon general reports and NCHS. Smoking rates are prominence, helped in part by a December 2001 “Call twice as high for young white women as for young black to Action” by former Surgeon General David Satcher, as or Hispanic women. Smoking is nearly three times as well as by the efforts of his successor, Richard H.
common among women without a high school diploma Carmona. It parallels, in many ways, the more estab- as among women who completed college. Weight is par- lished antismoking message, which has been pushed by ticularly problematic among black women, half of whom U.S. surgeons general since the 1960s and which has are obese; it is also strongly related to income: One contributed to dramatic declines in smoking rates.
study found that women at or below 130% of the federalpoverty level were about 50% more likely to be obese Two Epidemics
Such campaigns are pursued because smoking and obe-sity are two of the leading causes of preventable mortal- Reproductive Health Impacts
ity and morbidity in the United States. Both are risk Smoking and obesity have a wide range of effects spe-cific to reproductive health. One or both can be nega- The Guttmacher Report on Public Policy
tively linked to everything from puberty to breastfeed- Family Planning’s Relevance
ing to cervical cancer. For reproductive health care Given this long list of negative impacts, helping women providers, the three areas in which smoking and obesity to avoid smoking and obesity in the first place clearly may have the most directly relevant impacts are preg- would improve their reproductive health. And for those nancy outcomes, fertility and contraceptive choice.
already affected by one or both conditions, smokingcessation and weight loss can reverse many of the risks In terms of the impact on pregnancy, the surgeon gen- associated with pregnancy, fertility and contraceptive eral’s report concludes that smoking is associated with use. The surgeon general’s report on smoking, for stillbirth and neonatal death, and it may increase instance, concludes that women who quit before or dur- ectopic pregnancy and spontaneous abortion. Infants ing pregnancy reduce their risk for infertility, low birth born to smokers tend to be low-birth-weight and small weight and several other adverse outcomes.
for their gestational age. The March of Dimes notes thatobesity and diabetes are associated with maternal and Reproductive health providers, and particularly the fetal complications, including birth defects, miscarriage national network of some 7,000 family planning clinics across the country, are especially well suited to help.
Together, these clinics reach out to 6.6 million women Despite the well-publicized consequences of maternal each year; eight in 10 of their clients are under age 30 smoking, 12% of new mothers reported that they smoked and nine in 10 have low or marginal incomes (under while pregnant in 2001, and CDC considers these data 250% of the federal poverty level). In fact, according to to be a low estimate. The maternal smoking rates are a 2001 analysis by The Alan Guttmacher Institute twice or three times this overall rate for young white (AGI), women who obtain their reproductive health teens and women, and they differ immensely by educa- care from family planning clinics are more likely than tion—43% among white women who attended but did those who receive such care from private physicians or not finish high school compared with 2% among college HMOs to be young, black or Hispanic, uninsured or on graduates. Although four in 10 smokers stop while they Medicaid, and to have not completed high school (see are pregnant, seven in 10 of those relapse within oneyear of delivery.
In terms of fertility, the surgeon general’s report found ON TARGET
that women who smoke find it more difficult to conceive The clients of family planning clinics are especially
than nonsmokers, that smoking is positively associated likely to have characteristics that put them at high risk
with infertility and that smoking may be detrimental to of smoking or obesity.
in vitro fertilization. Papers prepared for the AmericanSociety for Reproductive Medicine estimate that 13% of Aged 15–19
female infertility is caused by smoking and that 6% is caused by obesity; both factors may also impair male Aged 20–24
Smoking and obesity are also limiting factors in terms of women’s contraceptive choice, and the evidence sug- gests that obesity may reduce contraceptive efficacy as well for at least some hormonal methods. The surgeon Hispanic
general’s report concludes that women (especially older women) who smoke and use oral contraceptives haveespecially high risk for heart disease. The prescribing Less than high school degree
information for combined hormonal contraceptives warns explicitly of these problems and strongly adviseswomen who use these methods not to smoke. Obesity Medicaid
contributes to hypertension, diabetes and other cardio- vascular risk factors that may preclude the use of some Uninsured
hormonal contraceptives. Moreover, several studies have indicated that high body weight decreases the effectiveness of some hormonal contraceptives (by 60%, according to a study published in the May 2002 issue of Obstetrics & Gynecology).
Source: Frost JJ, Public or private providers? U.S. women’s use of reproductivehealth services, Family Planning Perspectives, 2001, 33(1):4–12.
The Guttmacher Report on Public Policy
chart). Those groups of women have been cited as tar- planning clinics found that a large proportion of these gets for antismoking and antiobesity activities because agencies offer nutrition counseling and smoking cessa- of their high or increasing rates of the two conditions.
tion services. Not surprisingly, hospitals and agencieswith more comprehensive health programs are more Furthermore, family planning providers—who have sub- likely than more specialized reproductive health agen- stantial experience and expertise providing counseling cies to offer these services (see chart).
and education on healthy behaviors and behaviorchange—are interacting with these women at points in This situation may be changing, particularly for smok- their life that may be especially opportune for antismok- ing cessation. Planned Parenthood Federation of ing and antiobesity messages. Young women in general America (PPFA) is writing new standards and guidelines are critical to reach, as lifestyle habits, including smok- on smoking cessation in response to requests from its ing, diet and exercise, are often formed early in life and affiliates, according to Vanessa Cullins, vice president may be difficult to change later. To the extent that these for medical affairs. PPFA is also exploring the idea of women are weighing their contraceptive options, infor- guidelines relating to weight loss and obesity. Cullins mation about the dangers of smoking and the impor- adds that a number of Planned Parenthood affiliates are tance of good nutrition are directly relevant. And already offering services such as smoking cessation.
because a central family planning service is preconcep- And, of course, Planned Parenthood providers (as well tion counseling and education, women in family planning as other family planning providers) are guided in theirclinics who are considering pregnancy can be encour- client counseling and education by published medical aged, if necessary, to alter their behavior in advance of becoming pregnant so as to encourage the best possiblehealth outcomes for themselves and their child.
ACOG, too, is looking to expand its antismoking effortsbeyond its traditional focus on pregnancy. With support What Is Being Done
from DHHS, ACOG is helping to set up state-level part-nerships among maternal and child health–related Reducing smoking among pregnant women, in particu- providers, and smoking has been a top priority. The lar, has long been a goal shared by providers and advo- group has also worked with the Women’s Tobacco cates within and outside of the reproductive healthcommunity. For example, the American College ofObstetricians and Gynecologists (ACOG), in November PREVENTIVE SERVICES
2002, published a provider guide for smoking cessationduring pregnancy that focuses on a quick (5–15 min- Agencies that administer family planning clinics are
utes) and proven counseling method. They have dis- relatively more likely to provide nutrition counseling
seminated such information and pursued other anti- and smoking cessation services if they have a more
smoking strategies in collaboration with Smoke-Free comprehensive health care program.
Families, a Robert Wood Johnson Foundation–funded Community/migrant health center
program that is coordinating the National Partnership to Health department
Meanwhile, the program guidelines for Title X–funded family planning projects include a number of recom- Hospital
mendations that are relevant to nutrition, exercise and smoking cessation. They note that at a patient’s initial comprehensive clinical visit, a complete medical history Planned Parenthood
must be obtained, which must address chronic or acute medical conditions and the use of tobacco and othersubstances. For female clients, a complete physical Reproductive health focus
examination should also be performed, as “for many clients, family planning programs are their only continu- ing source of health information and clinical care.” The Broader focus
guideline’s recommendations for client education and counseling also include the topics of nutrition, exercise,smoking cessation and substance use and abuse.
An AGI study, published in 2002, of health depart- ments, hospitals, Planned Parenthood affiliates and Source: Finer LB, Darroch JE and Frost JJ, U.S. agencies providing publicly other types of agencies that run publicly funded family funded contraceptive services in 1999, Perspectives on Sexual and ReproductiveHealth, 2002, 34(1):15–24.
The Guttmacher Report on Public Policy
possible impact on body image, including the danger of MEDICAID GAPS
eating disorders and of increased smoking, which is Many states have chosen not to cover treatment for
sometimes used as a tool for staying slim.
smoking and obesity.
Lack of reimbursement may be the most serious barrier,however. A report by the Partnership for Prevention found that in 1997, only about one-quarter of employer-sponsored health plans covered smoking cessation devices and drugs or counseling for either smoking cessa- tion or nutrition and physical activity. Medicaid coveragefor smoking cessation is also scanty, according to a May CDC report; perhaps most striking is the small propor-tion of state Medicaid programs that provide reimburse- ment for counseling. Similarly, state Medicaid programs typically exclude coverage for obesity, including drugs forweight loss, according to the American Obesity Association (see chart). The barrier may be psychological as well as practical: ACOG’s Mahoney suggests that by failing to reimburse providers even a little, insurers send the message that these efforts are not valued.
Providers of subsidized family planning services are *Without restriction to a narrow list of conditions. Sources: Halpin HA, et al., already operating under severe financial constraints State Medicaid coverage for tobacco-dependence treatments—United States, (“Nowhere But Up: Rising Costs for Title X Clinics,” 1994–2001, Morbidity and Mortality Weekly Report, 2003, 52(21):496–500;American Obesity Association, Medicaid reimbursement for prescription TGR, December 2002, page 6). Those seeking to expand weight-loss drugs, <http://www.obesity.org/treatment/medicaid.shtml>, or augment their antismoking and antiobesity activities may be heartened by the potential availability of newsources of federal support in these areas. The DHHS Prevention Network, formed at the behest of CDC in community-grant program announced in May, for 2001 to target women as a priority for prevention. On instance, is allocating nearly $14 million for FY 2003 to the obesity front, ACOG released in July a new mono- prevent diabetes, asthma and obesity through such graph about weight control that provides doctors with a measures as improving nutrition, increasing physical detailed overview of how obesity comes about and of activity and reducing tobacco use. The administration’s options for screening, counseling and treatment.
budget for FY 2004 asks for a major increase, to $125million. The Frist legislative proposal would allocate $60 Barriers for Providers
million per year for provider training, community-based Many of these new efforts are aimed at provider educa- programs and government research relating to improved tion and mobilization, reflecting a belief that providers’ nutrition, increased physical activity and obesity pre- lack of knowledge, training or—for whatever reason— vention. These grants would add to federal funding motivation can be barriers to patients’ care. Jeanne already provided to state health agencies, including Mahoney, director of ACOG’s provider’s partnership $100 million from CDC for tobacco use prevention and project, for example, believes that family planning $34 million for nutrition, physical activity and obesity.
providers are already feeling overwhelmed and that itmay seem to them that even a short counseling inter- The extent to which the proposed new funding actually vention is too long to add into a family planning visit.
will materialize remains to be seen. What also remains Nevertheless, she believes in the “drop-in-the-bucket to be seen is the extent to which family planning clinics theory”—that small actions by a provider (e.g., a refer- will be able to gain access to new and existing funds for ral or a small amount of counseling) add up over time, their antismoking and antiobesity programs. It would particularly as multiple providers add to the message.
certainly appear, however, that policymakers are mak-ing smoking cessation, obesity prevention and other Another concern for some providers is that a poorly tai- lifestyle changes a priority. And there is little doubt that lored message has the potential to alienate or even family planning providers are well equipped to make harm their patients. Kathleen Baldwin, vice president valuable contributions to those efforts.
for education and training at Planned Parenthood of This article was supported in part by the U.S. Department of Health Greater Indiana, is working with a coalition on obesity and Human Services under grant FPR000072). The conclusions and in Indianapolis. One of her objectives, she says, is to opinions expressed in this article, however, are those of the author keep the coalition conscious of an antiobesity message’s and The Alan Guttmacher Institute. The Guttmacher Report on Public Policy
hiv building BUILDING BLOCKS: Comprehensive Care Guidelines for Persons Living with HIV/AIDS in the Americas SUMMARY REPORT June 2000 PAHO/WHO in collaboration with UNAIDS and IAPAC Acknowledgements The text of this document was prepared by the Regional Program on AIDS/STI, Pan AmericanHealth Organization (PAHO), Regional Office of the World Health Organization. It is