SMOKING CESSATIONIN PREGNANCY

Department of Health and Mental Hygiene

Center for Health Promotion, Education and Tobacco Use Prevention

http://www.fha.state.md.us/ohpetup/

ORDER OF PRESENTATION Background: Pregnant Smokers in MD and

the US Factors influencing smoking cessation &

maintenance among women Health Effects: maternal, fetal, infant/child Intervention: Smoking Cessation In

Pregnancy (SCIP) Transtheoretical Model of Change Motivational Interviewing Teen Intervention: Arrive in Style Role Play Exercises Review

US Facts: Women and Smoking (Surgeon General’s Report on Women and Smoking,

2001)

• 22% of women 18+ years smoke

• 15% of female 8th graders smoke

• 30% of female 12th graders smoke

• 165,000 + women died from smoking-related diseases in 1999

US Facts: Smoking Prevalence of Women by Race/Ethnicity ‘97-’98

(Women and Smoking: A Report of the Surgeon General-2001)

• 34.5% American Indian/Alaskan Native

• 23.5% white

• 21.9%African American

• 13.8% Hispanic

• 11.2% Asian Pacific Islander

The Facts: Maryland

•13.6% of women smoke (2002 Maryland Adult Tobacco Study)

•4.9% of middle school girls smoke

(2002 Maryland Youth Tobacco Survey)

•17.9% of high school girls smoke (2002 Maryland Youth Tobacco Survey)

•2,844 women died of smoking-related diseases in 1999

(2002 Tobacco Control State Highlights, CDC)

4.9

17.9

13.6

0

2

4

6

8

10

12

14

16

18

Per

cen

t

Female

Cigarette Use by Age

Middle School High School Women

(DHMH, First Annual Tobacco Study, 2002)

10.6

20.5

13.9

5.6

17.118.3

19.4

16.9

0

5

10

15

20

25

Per

cen

t

African American Asian Hispanic White

Cigarette Use by Age and Race/Ethnicity

Youth Adult

(DHMH, Initial Findings from the Baseline Tobacco Study, 2000)

• 25% of women use tobacco during pregnancy (health dept. population)

(Maryland Prenatal Risk Assessment, 7/00-6/01)

• 8.0% of women use tobacco during pregnancy (general population)

(Maryland Vital Statistics, 2002)

Tobacco Use During Pregnancy

Profile: The Pregnant Smoker

• White

• Unmarried

• 25.5% less than high school education

• 67% resume smoking in first year after delivery

• 60% rely on local health departments and/or Medicaid as source of care/payment(Smoke-free Families Nat’l Program Office)

• 3.8% heavy smokers• 25% quit upon learning they are pregnant

(Women and Smoking: A Report of the Surgeon General-2001)

Factors Influencing SmokingAmong Women

(Women and Smoking: A Report of the Surgeon General-2001)

• More addicted to cigarettes• Less ready to stop smoking• Dependence on smoking for

weight control• Response to stress• Less social support for quitting• Less confident in resisting

temptation to smoke• Tobacco Marketing

Maternal Health EffectsWomen and Smoking: A Report of the Surgeon General-2001)

• Miscarriage• Premature birth• Ectopic

pregnancy• Placental

abnormalities• Bleeding• Premature

rupture of membranes

• Impaired lactation

• Inhibited protection against SIDS from breast milk

During Pregnancy Postpartum

Long-term Maternal Effects

(Women and Smoking: A Report of the Surgeon General-2001)

• Decreased life expectancy

• Heart Disease• Cancer• Embolism &

Stroke• Emphysema• Decreased fertility

•Menstrual abnormalities

•Earlier menopause

•Increased risk of osteoporosis

•Premature aging of the skin

•Muscular degeneration

Health Effects on Fetus

• Fetal Growth Retardation

• Small for gestational age

• Increased fetal heart rate

• Chronic Fetal Hypoxia

• Perinatal death

• Preterm delivery

• Low Birth Weight

• Fetal artery constriction

• Lessened amounts of oxygen and nutrients in the fetus

(DHHS, 1990; ACOG, 1997; Smoke-Free Families National Program Office and ACHS, 1996)

• Sudden Infant Death Syndrome (SIDS)

• Respiratory tract infections

• Colds• Ear infections• Reduced lung

function• Diabetes

Health Effects On Children(Environmental Tobacco Smoke)

• Asthma• Pneumonia and

Bronchitis• Childhood and

adult cancers• ADHD• Increased

likelihood of becoming smokers

(American Lung Association, 2001)

Why is Pregnancy is an ideal time to quit smoking? (Sprauve, 1999)

• Dual (2 for 1) benefit• Initial enthusiasm is high to quit• Increased contact with health care providers• Dose-response relationship• Quit rates increase 10%-20%• Low birth weight decreases by 25%• Infant mortality rate decreases by 10%

SCIP History

When: 1988 by a federal grant

What: A smoking cessation intervention for pregnant smokers

How: Training of local health department staff and managed care organizations to facilitate quitting or reducing cigarette consumption among

pregnant women.

SCIP GOALS

By 2003, reduce the infant mortality rate in Maryland to no more than 7.8

By 2002, reduce the percentage of low birth weight babies in Maryland to no more than 8.5

Healthy Maryland 2010

Infant Mortality Rate (IMR)– reduce the IMR to no more than 6.0 per 1,000

live births (IMR was 7.4 per 1,000 in 2000)

Low Birth Weight (LBW)– reduce LBW to no more than 8.0% (LBW was

8.7% in 2000)

IMR and Healthy People 2010 Objectives by Race, Maryland, Selected Years, 1989-2010, and the U.S. 2010 Objective for All Races

9.7

16.3

8.6

15.3

6

12.7

4.5 5

0

2

4

6

8

10

12

14

16

18

Live births per 100,000

1989-1993(avg.)

1994-1998(avg.)

2010Objective MD

2010Objective US

All Races African-American

Maryland’s Health Improvement Plan, 2001

SCIP OBJECTIVES

Motivate and Assist pregnant women in quitting smoking

• move women along stages of change continuum• increase number of quit attempts

Inform pregnant smokers about smoking-related risks

Assist in maintaining a smoke-free lifestyle

Elements of SCIP

Patient Self-help Materials– Quit & Be Free Client Manual– Quit Kit

Element #1

Manual

Quit Kit

Toothbrush/Toothpaste

Relaxation Tape

Paper Clips

Baby Shirt

Pen

Cinnamon Sticks

Rubber Bands

Element #2

Brief Counseling Intervention– 5 A’s for Brief Smoking Cessation Counseling for

Pregnant Women(U.S. Department of Health and Human Services)

•Ask•Advise•Assess•Assist•Arrange

ASK

ADVISE

ASSESS

ARRANGE

ASSIST

5 A’s

#1 ASK

Identify and document smoking status for every client at each visit

client about tobacco use...

#2 ADVISE

Need for change – given in a non-authoritarian and supportive style

client of…

Health hazards of smoking

Benefits of quitting

#3 ASSESS

Asking open-ended questionsEliciting self-motivational

statementsListening Reflectively (listening

with empathy)Affirming the clientSummarizing

client’s readiness to quit stage…

#4 ASSIST

Positively reinforce past attempts to quit

Help client to identify barriers and solutions

Communicate free choice

Give support and confidence in patient’s ability to quit

Elicit other sources of support (i.e., family, friends)

Consequences of action/inaction

Discuss a plan (elicited from client)

Ask for commitment Offer client Quit and

Be Free manual & Quit Kit

client in making a quit attempt...

#5 ARRANGE

Schedule next counseling session• Work with client on what is achievable

between now and next appointment• Summarize what actions client has agreed to

do before next appointmentFollow-up phone call in two

weeks

follow-up with client...

5 A’s

ASK

Smoking status

ADVISE•Health effects

•Need for change

Readiness to quitASSESS

In quittingASSIST

Follow-up•Documentation

•phone call (2 wks.)

ARRANGE

Stage IPre-

contemplation

Stage II Contemplation

Stage III Preparation

Stage IV Action

Stage V Maintenance

STAGES OF CHANGE(adapted from DiClemente and Prochaska)

Patient not interested changing

Patient will examine benefits & barriers to change

Patient will incorporate change into daily lifestyle

Patient will take decisive action

Patient will discover elements necessary for decisive action

Client enters

client exits

Stages of Change(Prochaska and DiClemente, 1983)

• Pre-contemplation - not interested in quitting• Contemplation - more open to the possibility

of quitting and how to do it• Preparation - taking small steps in learning

more about quitting, cutting down• Action - quitting the habit, seeking social

support, coping mechanisms• Maintenance - smoke-free• Relapse - return to smoking

Stages of Change & Opportunities for Health Professionals

• Pre-contemplation– Use relationship building skills– Personalize risk factors– Use teachable moments– Educate in small bits, repeatedly, over time

• Contemplation– Elicit reasons to change/consequences of not changing– Explore ambivalence; praise client for considering the

difficulties of change– Question possible solutions for one barrier at a time– Pose advice gently as “a solution

(Zimmerman, Olsen, Bosworth, 2000)

• Contemplation

Stages of Change & Opportunities for Health Professionals (cont.)

• Preparation– Encourage client efforts

– Ask which strategies the client has decided on

for risk situations

– Ask for a change date

•Action– Reinforce the decision– Delight in even small successes– View problems as helpful information– Ask what else is needed for success

Stages of Change and Opportunities for Health Professionals (cont.)

• Maintenance– Continue reinforcement– Ask what strategies have been helpful and what

situations problematic

Readiness to quit

Follow-up•Documentation

•phone call (2 wks.)

ASK

ADVISE

ASSESS

ARRANGE

In quittingASSIST

•Health effects•Need for change

5 A’s

Smoking status

Stagesof

Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Motivational Interviewing (M.I.) (Rollnick, S., & Miller, W.R. 1995)

“Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”

Five Principles of M.I.

1. Express Empathy

2. Develop Discrepancy

3. Avoid Argumentation

4. Roll with Resistance

5. Support Self-Efficacy

1. Express Empathy

•Create a warm, supportive, patient-centered atmosphere

•Empathic, reflective listening is essential

Remember that Acceptance facilitates change, Pressure to change blocks it

2. Develop Discrepancy

•Patient should present arguments for change

•Motivate discrepancy in the patient

(where the patient wants to bev.

where they are right now)

3. Avoid Argumentation

•Keep patient resistance levels LOWMore resistance = Less likely to change

“Denial is not a problem of patient personality, but of therapist skill”

4. Roll with Resistance

•Opposing resistance generally reinforces it •DON’T PUSH!!!

•“Roll with” the momentum with a goal of shifting client perceptions(Motivational Enhancement Therapy Manual, Vol. 2, 1999)

5. Support Self-Efficacy

•Impart belief about possibility of change

•Remember it is always the patient’s choice whether or not to change

Readiness to quit

Follow-up•Documentation

•phone call (2 wks.)

ASK

ADVISE

ASSESS

ARRANGE

In quittingASSIST

•Health effects•Need for change

5 A’s

Smoking status

Stagesof

Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

DevelopDiscrepancy

AvoidArgumentation

Roll withResistance

SupportSelf-efficacy

ExpressEmpathy

MotivationalInterviewing

Date of 1stVisit:

__/___/___

Trimester:1

2

3

PP

# Cigs. in last24 hrs:_____

Interest in Quitting:

Not interested

Interested, butnot ready

Taken Steps toquit

Ready to quit

Smoke-free

Topicsdiscussed?

Benefits

Support

Strategies

Client agrees to:

Think about quitting

Cut down # of cigs.

Set a quit date:_____

Prepare to quit

Quit

tay smoke-free

Problems/Barriers:

Goal for next visit:

Initials:______

Date ofVisit:

__/___/___

Trimester:1

2

3

PP

Did ClientQuit?

Yes

_No

# Cigs. in last24 hrs:_____

Interest in Quitting:

Not interested

Interested, butnot ready to quit

Ready to quit

Topicsdiscussed?

Benefits

SupportStrategies

Client agrees to:

Think about quitting

Cut down # of cigs.

Set a quit date:_____

Prepare to quit

Quit

Stay smoke-free

Problems/Barriers:

Goal for next visit:

Initials:______

Date of Follow-upcall:

__/__/____

Comments:

Date ofVisit:

__/___/___

Trimester1

2

3

PP

Did ClientQuit?

Yes

No

# Cigs. in last24 hrs:_____

Interest in Quitting:

Not interested

Interested, butnot ready to quit

Ready to quit

Topicsdiscussed?

Benefits

SupportStrategies

Client agrees to:

Think about quitting

Cut down # of cigs.

Set a quit date:_____

Prepare to quit

Quit

Stay smoke-free

Problems/Barriers:

Goal for next visit:

Initials:______

Date of Follow-upcall:

__/__/____

Comments:

Element #3•Documentation & Follow-up

Arrive in Style Teen Intervention

4.9

17.9

13.6

0

2

4

6

8

10

12

14

16

18

Per

cen

t

Female

Cigarette Use by Age

Middle School High School Women

(DHMH, First Annual Tobacco Study, 2002)

Arrive in Style Goals

To educate female teen smokers about smoking-related health risks

To motivate teen smokers to quit

To provide support to successfully quit and maintain a smoke-free lifestyle

Arrive in Style Teen Intervention

1. Full color magazine

2. Brief counseling intervention

3. Documentation

4. Evaluation card

Elements:

Arrive in StyleCounseling Intervention

ASK client about tobacco useADVISE of harmful effects,

benefits of quitting, the need for change

ASSESS readiness to quit stageASSIST in making a quit attemptARRANGE next appointment

– Summarize what actions client has agreed to do before next visit

– Follow-up phone call in two weeks

Counseling Teens

1. Be Positive•Praise them for seeking health care early and taking good care of themselves

2. Immediate Benefits of Cessation•Appearance•Cost

3. Short-term benefits•Less coughing, breathing easier

ReviewElements:

SCIP Teen Intervention

1. Self Help Materials»Quit & Be Free » Arrive in Style

»Quit Kit

2. Brief Counseling Intervention– 5 A s of Cessation Counseling» Ask » Advise

» Assess » Assist » Arrange

3. Documentation & Follow-up

» Documentation Form » Documentation Form » Follow-up phone call » Follow-up phone call

» Evaluation Card

Readiness to quit

Follow-up•Documentation

•phone call (2 wks.)

ASK

ADVISE

ASSESS

ARRANGE

In quittingASSIST

•Health effects•Need for change

5 A’s

Smoking status

Stagesof

Change

Precontemplation

Contemplation

Preparation

Action

Maintenance

DevelopDiscrepancy

AvoidArgumentation

Roll withResistance

SupportSelf-efficacy

ExpressEmpathy

MotivationalInterviewing