Transcript Document

BEST PRACTICES FOR
PREVENTION OF
PRENATAL SMOKING
Smoking for Two
The Size of the Problem in Indiana
• National average of prenatal smoking
is 11%
• Almost 19% of Indiana pregnant
women
• 17,000 new mothers smoke during
pregnancy each year in Indiana
prepared
by OMPP
DMA
February 2009
Medicaid: Pregnant Women and Smoking
StatusCY07
Counties >1,000 Births:
County
Births
Marion
Lake
Allen
St. Joseph
Elkhart
Vanderburgh
Tippecanoe
8,781
3,652
2,603
1,934
1,724
1,259
1,001
% Smoking
21%
15%
24%
21%
23%
33%
24%
Top 10 Counties by Rate of Smoking
County
Births
% Smoking
Lagrange
Washington
Perry
Dekalb
Fayette
Morgan
Blackford
Ripley
Montgomery
Scott
Shelby
126
162
115
290
203
454
109
164
273
199
286
48%
48%
47%
44%
44%
44%
43%
43%
41%
41%
41%
Data Source: ISDH/Medicaid combined birth record data. Singleton births during CY07. 2005 statewide average for smoking during pregnancy is
17.9% (ISDH Maternal and Child Epidemiology Reports) Women that indicated smoking during or prior to pregnancy were included.
Important Note: The majority of counties (68) have 30% or more Medicaid women attesting to smoking during pregnancy.
Data prepared by OMPP DMA
Page 4
February 2009
Cost Impact of Prenatal Smoking
• Increases the risk of prematurity by 30%
• Average hospitalization cost for a premature
infant is $50,000 more than that of a full-term
infant
• Prenatal smoking in Indiana adds an additional
cost of $28 million for mothers and infants for the
initial hospitalization related to prematurity
Physician Attitudes About
Prenatal Smoking Counseling
• Study of Tennessee Physicians
• 2/3 always give their pregnant smokers advice
to quit
• More than ½ reported always assessing
willingness to quit
• ¼ or fewer always provided quit assistance, or
arranged follow up.
Physician Attitudes About
Prenatal Smoking Counseling
• What is the degree of health effects on the
unborn child from the mother smoking during
pregnancy?
• Severe effect 35
• Modest effect 65
• Minor effect 0
• What is the value of using time during the
clinical encounter to give brief smoking
cessation counseling to pregnant smokers?
• Significant value 59
• Modest value 24
• Limited value 1
•
Bailey, Beth A. PhD; Jones Cole, Laura K. MS, MA Southern Medical Journal:September 2009 - Volume 102 - Issue 9 - pp 894-899
• How interested are you in learning best practice
guidelines and techniques for assisting pregnant
smokers?
• Very interested/interested
53%
• Not at all/minimally interested 18%
• How willing would you be to participate in a
CME certified training program at your practice
outlining best practices techniques for helping
pregnant smokers quit?
• Very willing/willing
53%
• Very unwilling/unwilling 35%
• How willing would you be to allow nursing staff
to participate in a best-practice training
program for helping pregnant smokers quit?
• Very willing/willing
82%
• Very unwilling/unwilling 6%
Barriers to Physicians Providing
Prenatal Smoking Counseling
• Lack of time
• Patients preoccupation with other concerns
• Patient’s other substance use takes priority
• Potential effectiveness of an intervention attempt
• Previous failures in persuading patients to quit
• Lack of skill in counseling for prenatal smoking
• Avoid conflict
• Limited reimbursement (Indiana $9.72 for 3-10
minutes)
• Lack of referral services
• “Smoking is not an immediate danger”
Physician Attitudes About
Secondhand Smoke
• 82% of respondents indicated they were
not regularly asking their pregnant patients
about SHS
• 47% felt it was only “Minimally Important” to
discuss SHS
CONTRIBUTING FACTORS,
WOMEN’S ATTITUDES AND
DETERMINANTS OF
SMOKING DURING
PREGNANCY
Determinants
• Poverty
• Smokers tend to have a lower social class and income
• Education
• Pregnant smokers have less education
• Age
• Younger women are more likely to smoke
• Self-confidence, efficacy
• Women lacking self-confidence and self-efficacy are
more likely to continue smoking during pregnancy
Ingall & Cropley, 2010; Women and Birth
Lu, Tong & Oldenburg, 2001; Health Promotion International
Contributing Factors
• Partner/spouse’s smoking status
• Level of addiction
• < 5 cigarettes/day-18 times more likely to stop
compared to those smoking >20
• Multiparity
• Awareness of risks - “this won’t happen to
me”
Schneider, Huy, Schutz, & Diehl, 2010; Drug and Alcohol Review
Lu, Tong & Oldenburg, 2001; Health Promotion International
Determinants
• Depression
• Depression is a predictor of smoking cessation
• PHQ-9 Screening Tool
• http://www.depression-
primarycare.org/clinicians/toolkits/materials/for
ms/phq9/
• Poor social support
Orr, Blazer & Orr, 2011; Maternal and Child Health Journal
Nichter et al., 2007; Health Education & Behavior
INTERVENTION
PROGRAMS
Baby & Me – Tobacco Free Program
• Developed in 2002 in New York state
• Incentive-based program to increase smoking
cessation in women during and after
pregnancy
• A quit rate of 60% at 6 months post partum
• Used in: New York, Colorado, North Dakota,
Nebraska and Oregon
http://babyandmetobaccofree.org/
Baby & Me – Tobacco Free Program
Program Requirements
Commit to quit.
• Quit smoking while pregnant and stay quit
after baby is born
Baby & Me – Tobacco Free Program
Program Requirements
Attend at least 4 smoking cessation counseling sessions.
• 1st Self-help materials, and information on how to
quit
• 2nd Secondhand smoke, partners who smoke,
and establishing smoke-free homes and cars
• 3rd Stress management and benefits of not
smoking
• 4th Relapse prevention and postpartum incentive
program
Baby & Me – Tobacco Free Program
Program Requirements
Agree to submit to breath tests.
• Carbon monoxide breath tests were
conducted at each counseling session
• Monthly breath tests postpartum
Baby & Me – Tobacco Free Program
Program Requirements
After the baby is born, stay smoke free and receive a
monthly voucher for FREE DIAPERS up to one year
after the birth of the baby
• For every negative monthly carbon
monoxide breath test, the mother received
a $20 voucher for diapers at chain
supermarkets
Baby & Me – Tobacco Free Program
Model 1
Model 2
Model 3
Pregnancy quit rate
61.0
50.0
60.5
Quit @ 3 months postpartum
52.0
37.5
77.0
Quit @ 6 months postpartum
32.0
25.0
64.0
Quit @ 12 months postpartum
9.0
0.0
44.0
• Model 3 was the most intensive, used trained smoking
cession specialists, and had highest postpartum quit rates
• Higher nicotine addictions is a predictor of dropout
Wisconsin First Breath
• Focuses on integrating cessation strategies into
pre-existing prenatal care models
• Implemented in 2001
• Enrolled over 10,000 women
• 34% of enrolled participants quit smoking
• Combats relapse by encouraging recent quitters
to enroll
http://www.wwhf.org/programs/first-breath/
Wisconsin First Breath
Women who participate in the First
Breath program receive:
• Personal smoking cessation support
• Intensive smoking cessation counseling
• Educational and self-help materials
• Educational materials for their friends and family
Wisconsin First Breath
Women who participate in the First
Breath program receive:
• Free incentives for participation
• A gift at delivery
• Wisconsin Tobacco Quit Line materials,
information and access
Wisconsin First Breath
Cost Savings
• Medicaid saves $1,274 per enrollee who quit
• Every $1 spent saves $6 in health care costs
Smoking Cessation and Reduction in
Pregnancy Treatment (SCRIPT - SOPHE)
• Intervention components:
• A Pregnant Woman’s Guide to Quit Smoking
• Commit to Quit Smoking During and After
Pregnancy DVD
• Comprehensive counseling
• Encouragement and counseling to establish a
smoke-free home
http://www.sophe.org/SCRIPT.cfm
TRAINING PROGRAMS
AND OTHER RESOURCES
Training Programs, Resources
• ACOG
• Smoking Cessation During Pregnancy Guide
• Smoking Cessation for Pregnancy and Beyond
• http://www.acog.org/About_ACOG/ACOG_Departm
ents/Tobacco__Alcohol__and_Substance_Abuse/N
EW_Prenatal_Smoking_Clinician_s_Guide
• Marshall University
• Smoking Cessation & Beyond-Dartmouth
• You Quit, Two Quit
• PSUPP
• Smoke Free for Baby and Me - Michigan
Marshall University, web-based CME
http://musom.marshall.edu/medctr/med/tobaccocessation/pregna
ncyandsmoking/login.aspx
• https://www.smokingcessationandpregnancy.org/users/sign_in
Web Site (Consumers and Providers)
www.YouQuitTwoQuit.com
5As pocket guide
Ask, Advise, Assess, Assist, Arrange
American
College of
Obstetricians &
Gynecologists
Self-instructional
guide and tool kit
for health care
providers
http://www.youq
uittwoquit.com/P
rojectInfo.aspx
Indiana Prenatal Substance Use
Prevention Program
Smoke Free for Baby and Me
Michigan
• Michigan Department of Community Health’s (MDCH’s)
Division of Family and Community Health and the
Michigan Public Health Institute
• Web-based, prenatal smoking-cessation onlineeducational module
• https://learning.mihealth.org/SOLO/login.aspx
Incentive: Registered nurses who successfully complete
the course and the evaluation will receive 1.4 contact
hours.
The 5 A’s
• ASK – 1 minute
•
Ask patient about smoking status using the following structured
question:
A. I have NEVER smoked, or have smoked LESS THAN 100
cigarettes in my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant,
and I am not smoking now.
C. I stopped smoking AFTER I found out I was pregnant, and I
am not smoking now.
D. I smoke some now, but I cut down on the number of
cigarettes I smoke SINCE I found out I was pregnant.
E. I smoke regularly now, about the same as BEFORE I found
out I was pregnant.
• You Quit Two Quit - North Carolina Health and Wellness Trust Fund
The 5 A’s
• ADVISE – 1 minute
•
Provide clear, strong advice to quit with personalized
messages about the impact of smoking on mother and
fetus.
• ASSESS – 1 minute
•
Assess the willingness of the patient to make a quit
attempt within the next 30 days.
• ASSIST – 3 minutes +
•
Suggest and encourage the use of problem-solving
methods and skills for cessation.
Provide social support as part of the treatment.
Arrange for support in the smoker’s environment, such
proactive referral to the state quitline.
Provide pregnancy- and/or parent-specific, self-help
smoking cessation materials.
• ARRANGE – 1 minute
•
Periodically assess smoking status and, if she is a
continuing smoker, encourage cessation.
Counseling for Tobacco Cessation
• Counseling from the Heart – Three part video series from
the North Carolina Healthy Start Foundation
• http://www.youtube.com/watch?v=iPmMp6Eqtvk
• http://www.youtube.com/watch?v=wWiwb5RbLzI
• http://www.youtube.com/watch?v=qxJITjrxcCo
Quitlines
• California Quitline Study
• At the 3rd trimester evaluation, % quit
• 21% of the counseling group
• 13.5% of the self-help group
• Counseling subjects were more successful than
self-help subjects in avoiding relapse.
New York State Quitline
• Community-based promotion has been shown to increase
quitline utilization (Stead et al., 2003).
Effectiveness of Prenatal
Smoking Interventions
• Cochrane Review:
• 72 controlled trials involving over 25,000 women from
1975 to 2008
• 6% average smoking cessation during pregnancy
• Most effective intervention - 24% - involved incentives
• Smoking cessation interventions reduced the number of
babies with low birth weight and preterm births
HOW CAN WE BE MORE EFFECTIVE?
• California’s Best Practices At-A-Glance - 57%
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decrease during the 1990’s
1. **Support the “5As” in health care settings.
2. **Link with the California Smokers’ Helpline and other
counseling resources.
3. **Provide benefit coverage for counseling and
pharmacologic therapies.
4. Design culturally appropriate services.
5. **Institute smoking bans and restrictions.
6. **Increase the price of tobacco products.
7. Support media efforts.
• 8. Partner with colleges and universities to
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educate on-campus child care providers about
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the dangers of smoking.
• 9. Incorporate tobacco cessation services into
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school readiness programs.
10. **Include a tobacco cessation component in
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home visiting programs
• Community Guide for Supporting Effective Tobacco Cessation Services
- First 5 Association of California and the Center for Health Improvement
OTHER EFFECTIVE PRENATAL
PREVENTION STRATEGIES
• **Support from the physician, but counseling from other
personnel
• **Trained smoking cessation staff
• Screening for depression – PHQ-9
• http://www.depression-
primarycare.org/clinicians/toolkits/materials/forms/phq9/
• **Incentives
• **Use of self help guides, social support, and intensive
follow-up
• Involve faith-based organizations
• Intensive support from key community leaders
• Establish a culture of quitting
OTHER EFFECTIVE PRENATAL
PREVENTION STRATEGIES
• Carbon Monoxide Monitoring - Possible
• Nicotine Replacement Therapy – Controversial
• Harm Reduction Approach - Controversial
Links and suggested resources
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Wisconsin First Breath
http://www.wwhf.org/programs/first-breath/
Baby & Me – Tobacco Free Program
http://babyandmetobaccofree.org/
The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program
http://www.sophe.org/SCRIPT.cfm
Prenatal Substance Use Prevention Program (PSUPP)
http://www.in.gov/isdh/22243.htm
North Carolina You Quit, Two Quit
http://www.youquittwoquit.com/
Forever Free for Baby and Me
http://smokefree.gov/landing.aspx?rid=4
Smoking Cessation for Pregnancy and Beyond: A Virtual Clinic
https://www.smokingcessationandpregnancy.org/users/sign_in
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• Marshall University: Help Pregnant Patients Stop Smoking
• http://musom.marshall.edu/medctr/med/tobaccocessation/pregnancyandsmoking/l
ogin.aspx
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Counseling from the Heart: Helping Women Eliminate Tobacco Use and Exposure
http://www.nchealthystart.org/Womens%20Health/CounselingHeartVideo.htm
Smoking Cessation: Effective Intervention Strategies (web-based training)
http://nosmoking.msm.edu/
Smoke Free for Baby and Me (Michigan Department of Community Health model)
http://www.michigan.gov/mdch/0,1607,7-132-2942_4911_4912-12609--,00.html
Smoking Cessation During Pregnancy (provider instruction booklet)
http://www.acog.org/~/media/Departments/Tobacco%20Alcohol%20and%20Subst
ance%20Abuse/SCDP.pdf?dmc=1&ts=20120402T1119568260
• American Congress of Obstetricians and Gynecologists
(ACOG) - Smoking Cessation During Pregnancy
• http://www.acog.org/Resources_And_Publications/Commi
ttee_Opinions/Committee_on_Health_Care_for_Underser
ved_Women/Smoking_Cessation_During_Pregnancy
PHQ-9 Screening Tool
• http://www.depression-
primarycare.org/clinicians/toolkits/materials/forms/
phq9/
Effectiveness of quitlines
• Solomon et al. (2000) looked at the impact of physician/midwife advice to stop smoking
accompanied by printed materials, with and without proactive telephone peer support.
• Abstinence rate in the experimental group was 18.2%, which is consistent with
outcomes observed in other smoking cessation trials with pregnant women.
• Nearly 90% of the women considered the telephone counselors useful in helping
them change their smoking habits.
• Solomon et al. (2005), included pregnant smokers attending the Women, Infants, and
Children (WIC) program who accepted an offer to receive support by telephone from a
woman ex-smoker.
• Of the 948 pregnant smokers who were referred for telephone peer support, 25%
reported they were abstinent at their last telephone contact (defined as had not
smoked in the past 24 hours).
• Of the smokers who attended their post-partum WIC visit (n=625), 20% reported not
smoking in the last 3 months of their pregnancy and 14.6% reported they were
currently abstinent (defined as smoking zero cigarettes per day)
Solomon LJ, Secker-Walker RH, Flynn BS, Skelly JM, Capeless EL (2000).
Proactive telephone peer support to help pregnant women stop smoking. Tob
Control, 9 Suppl 3:III72-4.
Solomon LJ, Flynn BS (2005). Telephone support for pregnant smokers who want to
stop smoking. Health Promot Pract, 6(1):105-8.
• Study conducted by Zhu et al. (2003), pregnant callers (n=1,195) to the Zhu et al.
(2001)
• offer confidentiality
• require no transportation
• available at the smoker’s convenience
• bring services to smokers in rural areas, where there may be few resources.
• tailored for diverse language and cultural needs.
Zhu, S-H., Cummins, S.E., Anderson, C.M., & Tedeschi, G.J.
(2003, August). Telephone-based cessation intervention for
pregnant smokers: Results of a large randomized trial. Paper
presented at the 12th World Conference on Tobacco Or Health.
Helsinki, Finland.
Setting Universal Cessation Counseling Education and Screening
Standards(SUCCESS)
• Goals
• To educate nurses and other health car practitioners about smoking
cessation interventions.
• To increase the number of health care practitioners providing smoking
cessation interventions.
• To deliver an evidence-based smoking cessation intervention to
childbearing women who smoke to reduce/eliminate adverse birth
outcomes in this group, specifically low birth weight.
• Participants had a median of five follow-up encounter with health care providers with variable
amounts of time between encounters (due to different needs for care during pregnancy). During this
time, 22 of the 78 current smokers participating in the program were able to abstain for at least part
of the evaluation period (taking into account relapses, the program produced an effective quit rate of
21.5%) and another 25 reduced the number of cigarettes smoked each day. Furthermore, women
who quit smoking reported feeling healthier after they quit than at the start of the intervention.
Importantly, those women who were not able to quit reported that they advanced from the stages of
thinking about quitting smoking (precontemplation, contemplation, preparation) to the stage of
quitting.
Smart Mothers Are Resisting Tobacco (S.M.A.R.T. Moms) in TN
• Funded by March of Dimes office, this program partnered the Center with the
Tennessee Chapter of the March of Dimes and the Tennessee Department of
Health WIC offices throughout the state.
• Project outcomes include:
• At the conclusion of the 4-year project, 13,285 WIC patients received counseling and smoking
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cessation resources through the duration of the project
The overall success rate for participants who received counseling and agreed to use the selfhelp guide was 24.2% vs. 20.9% for those who did not choose to sue the self-help guide but did
receive counseling, exceeding success rates previously found in similar settings (14%).
Outcomes of this project support research that even brief tobacco cessation counseling (5 to 15
min) delivered by trained providers and coupled with pregnancy-specific self-help materials, can
increase cessation rates in women during pregnancy.
Outcomes from this project also support that when provided with adequate training and
pregnancy-specific self-help materials, health care providers will more consistently counsel
patients on smoking cessation during pregnancy.
The S.M.A.R.T. Moms project was honored through two awards. The National “Dr. Audrey
Manley” award, never before presented, and named for the former U.S. Surgeon General and
National March of Dimes Board of Trustees member, was presented to the S.M.A.R.T. Moms
project in October of 2005. This award recognizes an ‘exemplary program’ addressing the
needs of mothers and babies. The Tennessee Chapter of the March of Dimes was awarded the
“2004 Chapter of the Year Award” based on the S.M.A.R.T. Moms project which was highlighted
in the award application. The Tennessee Chapter competed with multiple states nationwide for
this prestigious award.
Colorado Prenatal Plus Program
• Medicaid-funded program that provides care coordination, nutrition and mental health counseling to
Medicaid-eligible pregnant women in Colorado who are at a higher risk for delivering low-birthweight
infants.
• Statistics of program
• Decrease in the rate of lowbirthweight infants from the expected rate of 13.7% to the actual rate
of 11.4%
• More than half (54 percent) of these Prenatal Plus Program participants were able to resolve all
of their risks (Smoking,Drugs,Alcohol,Psychosocial,Weight Gain), and the resulting lowbirthweight rate for their infants was 7.4% Compared to the low-birthweight rate for Colorado in
2006, 9.0%
• very low-birthweight rate among program participants was 1.1 percent, less than both the 2006
Colorado rate of 1.3 percent and the Healthy People 2010 goal of 1.4 percent.
• Each of the risk categories, more women were able to resolve their risk factors if they received
model care. 86% resolved all or some of their risks compared to 79% among those who did not
receive model care
• Model Care-Client enrolls in the Prenatal Plus Program in the 1st or 2nd trimester(prior to 28
weeks gestation) and continues through delivery and up to 60 days postpartum. The client must
receive a minimum of 10 contacts, two of which must be home or office-visits, with the Prenatal
Plus Staff.
Prenatal Smoking and Age Groups
•
Tong, VT, MMWR, May 29, 2009 / 58(SS04);1-29
• Women who smoked during pregnancy, by nicotine dependence and educational attainment:
National Epidemiologic Survey on Alcohol and Related Conditions, 2001–2002.
• Smokers average cost of birth $11,000
• Non smokers average cost of birth $6500
Prenatal Smoking-Impact on the Mother
Preterm delivery
 Premature rupture of membranes
 Ectopic pregnancy
 Placenta previa
 Abruptio placenta
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 Miscarriage