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Dissemination & Back Again: Developing a Research Methodology from Outcomes of a Community Prenatal Smoking Cessation Program PowerPoint PPT Presentation

Dissemination & Back Again: Developing a Research Methodology from Outcomes of a Community Prenatal Smoking Cessation Program Patricia Cluss, Ph.D. University of Pittsburgh School of Medicine/Psychiatry & the Pittsburgh STOP Program ReSET Roundtable January 27, 2009 Goals for Today

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Dissemination & Back Again: Developing a Research Methodology from Outcomes of a Community Prenatal Smoking Cessation Program

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Dissemination & Back Again:Developing a Research Methodology from Outcomes of a Community Prenatal Smoking Cessation Program

Patricia Cluss, Ph.D.

University of Pittsburgh

School of Medicine/Psychiatry

& the Pittsburgh STOP Program

ReSET Roundtable

January 27, 2009


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Goals for Today

  • Brief background on smoking during pregnancy

  • Evidence-based prenatal tobacco control

  • The Pittsburgh STOP Program: an E-B community program

  • Research questions suggested by evidence-based community program outcomes


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Health Risks of Smoking in Pregnancy

  • During pregnancy:

    • Growth retardation (low birth weight, length, head circumference)

    • Higher risk for ectopic pregnancy, miscarriage and premature delivery

  • After birth:

    • Negative long-term effects on children’s cognitive development

    • Negative effects on children’s growth (height)

    • Difficulty arousing from sleep (related to SIDS)


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How many women smoke during pregnancy?

  • Prevalence between 1990 and 2002 has reduced from 18% to 11%

  • In PA: 21% in 1990 to 16% in 2002

  • Pregnant women are about half as likely as nonpregnant women to be smokers.


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Who smokes during pregnancy?(Race & ethnicity; 1999 vs. 1990)

Was

22%

Was

21%

%

Was

16%

Was

7%

Was

6%

Source: National Center for Health Statistics


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Who smokes during pregnancy?

%


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Who is most likely tosmoke during pregnancy?

  • Low socioeconomic status (SES) (23% vs. 5%):

    • Least educated: high school or less

    • Lowest income: women on Medicaid are 2X as likely to smoke as those with private insurance

    • Low status jobs: of employed women, those with the lowest status jobs are 5X more likely to smoke than those with highest status jobs

  • Other factors:

    • High levels of pregnancy-related anxiety

    • High job stress

    • Exposure to physical/sexual violence


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Smoking during Pregnancy as a Health Care Crisis for the Underserved

  • At MWH prenatal clinic, 50% of pregnant women smoke.

  • Reducing smoking during pregnancy by 1% in U.S. over 7 years would prevent 57,000 LBW infants and save $572M in direct medical costs.


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Who is most likely to quitwhen pregnant?

  • 25% quit when they become pregnant (spontaneous quitters)

  • Lighter smokers

  • Older smokers

  • Those having their first baby

  • Those smoking for a shorter amount of time

  • More highly educated

  • Higher income

  • Have a partner who is a nonsmoker

15-30% relapse during pregnancy


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Goals for Today

  • Brief background on smoking during pregnancy

  • Evidence-based prenatal tobacco control

  • The Pittsburgh STOP Program

  • Research questions suggested by evidence-based community program outcomes


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Master Documents/Road Maps

  • Surgeon General 1964: Advisory committee’s report Smoking and Health

  • CDC:

    • 1999: Best Practices for Comprehensive Tobacco Control Programs

    • 2007: Update

  • Public Health Service:

    • 1996: Clinical Practice Guideline No. 18: Smoking Cessation

    • 2000: Treating Tobacco Use & Dependence

    • 2008: Update

  • IOM 2007: Ending the Tobacco Problem: A Blueprint for the Nation


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Rates of Smoking in the U.S.:Extremely Successful Public Health Campaign

Source: CDC


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Pittsburgh’s Least Well-Known Claim to Fame:

#1 in smoking during pregnancy

of any large US City*

Source: Annie E. Casey Fdn. Kids Count Special Report, 1999


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What works for smoking interventions in pregnancy?

  • Tailoring the intervention for pregnancy

  • Brief counseling of 5-10 minutes

  • Nicotine replacement therapy?? (Zyban, Chantix??)

  • Including nonsmoking partners in treatment??

  • Provide cessation interventions for smoking partners??


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Setting Goals: Quit vs. Cut Down?

Alcohol abuse

Substance abuse

Nonpregnant smokers

Pregnant smokers


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Working with disadvantaged pregnant smokers

  • Cessation programs are less effective for low vs. high SES smokers

  • Low SES women report more stressful events, more perceived stress, more negative appraisal from family, less social support & higher addiction to nicotine


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Interventions for low SES pregnant smokers should include:

  • More intensive interventions

  • Focus on reducing stress

  • Identification of depression & other MH needs

  • Increased focus on social support


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Translation/Dissemination of Research to Practice

X

Research

Evidence

Base

Clinical &

Community

Practice


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Goals for Today

  • Brief background on smoking during pregnancy

  • Evidence-based prenatal tobacco control

  • The Pittsburgh STOP Program: an E-B community program

  • Research questions suggested by evidence-based community program outcomes


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The Pittsburgh STOP (Stop TObacco in Pregnancy) Program

  • An outcomes-driven evidence-based program for underserved pregnant smokers

  • Over 1000 pregnant smokers and recent quitters (84%/16%) have participated since 2000

  • Based at WPIC with community outreach at Magee-Womens Hospital and other community health care locations/programs

Funding by: UPMC, March of Dimes, Tobacco Free Allegheny, PA DOH,

UPMC Health Plan, FISA Foundation


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Components

  • Coping strategies, problem solving skills, interpersonal support, NRT if MD willing

  • Attention to motivations for smoking and quitting

  • Menu of treatment options

  • Incentives for attendance (and, for some, abstinence)

  • Performance feedback (CO monitor)

  • Biological assessment of quit outcomes


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2008 SAMHSAScience and Service Award

  • Competitive national awards for exemplary implementation of recognized evidence-based MH or SA interventions and that make a positive impact in their communities.

  • 29 programs received awards in 2008.

  • STOP is one of two programs addressing tobacco and the only prenatal smoking cessation program to receive an award.


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STOP Participants

2000-2009:

  • 1170 participants

  • Age range: 14-42

  • 34% AA, 61% White

  • 90% MA or uninsured

  • 41% did not complete high school

  • 28% work outside the home

  • 87% single (but 80% in a relationship)

  • 84% unplanned pregnancy

  • 24% admit to co-occurring drug and/or alcohol abuse

  • 43% have sought treatment for depression

  • 76% of partners smoke


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STOP Participants

  • Main reasons for smoking:

    • Deal with stress (55%)

    • Addiction to nicotine (40%)

    • Social or other (5%)

  • Main reasons for wanting to quit or stay quit:

    • Baby’s health (84%)

    • My health (9%)

    • Save money (2%)

    • Break the addiction (3%)

    • Other (2%)


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Pittsburgh STOP ProgramReadiness-based recruitment & intervention strategies

Sure you can’t/don’t want to quit, but

willing to think about cutting down?

Thinking about quitting, but not sure?

Ready to quit?


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Originally built into the design as an evaluation measure to confirm self report of smoking status

Based on participant feedback, CO monitoring is now used as a program element to motivate change.

CO Monitoring


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What has been most helpful?

2%

5%


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CO Monitoring as a Motivator

  • Baseline score with printed (4th grade rdg. level) and verbal info about how higher levels of CO/lower levels of oxygen affect the mother and the fetus

  • Used as an example of other harmful physiological effects of smoking on mother and fetus

  • Weekly CO goals

  • Chart for ongoing CO monitoring


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STOP Program Results

  • Drop out rate low at 14%

  • Quit & stay quit rates:

    • 29.8% quit rate at delivery for those who enter as current smokers; most who do not quit do cut down

    • 90% stay-quit rate for those who enter as recent quitters


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Factors Associated withQuit Rate Results

  • Negative association for:

    • Treatment for depression (24% vs. 35%; p=.007)

    • Older than 25 vs. younger (24% vs. 35%; p=.006)

    • (trend) Partner who smokes vs. not (28% vs. 35%;p=.10)

    • (trend) White vs. AA (27% vs. 34%; p=.09)

    • (trend?) Unplanned pregnancy (29% vs. 36%; p=.12)

  • No differential outcomes for quitting by:

    • Concurrent alcohol or drug use

    • Exposure to domestic violence


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Birth Outcomes


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Gestational Age

Average gestational age of baby at birth

Preterm birth = less than 38 weeks

38.4 wks

37.9 wks

Gestational weeks

Average gestational age at birth:

Quitters: 38 wks 3 da

Smokers: 37 wks 6 da

p=.08


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Birth Weight Status

%

Average birth weights:

Quitters: 6 lbs. 14oz

Smokers: 6 lbs. 8 oz.

*c2 =4.6, p=.04


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Apgar scores by Smoking Outcomes

Birth:

F=2.9;p=.09

5 minutes:

F=4.1;p=.04


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Neonatal Outcomes

by Smoking Status

%

c2=6.2;p=.02


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Goals for Today

  • Brief background on smoking during pregnancy

  • Evidence-based prenatal tobacco control

  • The Pittsburgh STOP Program

  • Research questions suggested by STOP Program outcomes


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RCT Research Questions Suggested by STOP Outcomes

  • Does the STOP “package” improve outcomes for low SES pregnant smokers compared to usual care?

  • Do incentives motivate attendance, quitting, or both for low SES pregnant smokers?

  • Does CO monitoring motivate quitting?

  • Effectiveness of STOP interventionists vs. trained clinic staff interventionists


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Incentives:

Not reported as a motivator for quitting

May motivate attendance

Thus reducing drop out rate

CO Monitoring:

May motivate quitting

Thus:

Increasing quit rates

Decreasing relapse rates

Incentives & CO Monitoring:Guesses as to Mechanisms of Action


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2 x 2 research design

Incentives

Y

N

CO

+

incentives

CO

only

Y

CO monitoring

Incentives

only

Usual

care

N


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Patricia Cluss, Ph.D.

[email protected]

412 647-2933


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