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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 Goals for Today

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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

goals for today
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
health risks of smoking in pregnancy
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)
how many women smoke during pregnancy
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.
who smokes during pregnancy race ethnicity 1999 vs 1990
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

who is most likely to smoke during pregnancy
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
smoking during pregnancy as a health care crisis for the underserved
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.
who is most likely to quit when pregnant
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

goals for today10
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
master documents road maps
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
pittsburgh s least well known claim to fame
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

what works for smoking interventions in pregnancy
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??
setting goals quit vs cut down
Setting Goals: Quit vs. Cut Down?

Alcohol abuse

Substance abuse

Nonpregnant smokers

Pregnant smokers

working with disadvantaged pregnant smokers
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
interventions for low ses pregnant smokers should include
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
translation dissemination of research to practice
Translation/Dissemination of Research to Practice

X

Research

Evidence

Base

Clinical &

Community

Practice

goals for today19
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
the pittsburgh stop s top to bacco in p regnancy program
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

components
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
2008 samhsa science and service award
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.
stop participants
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
stop participants24
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%)
pittsburgh stop program readiness based recruitment intervention strategies
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?

co monitoring
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
co monitoring as a motivator
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
stop program results
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
factors associated with quit rate results
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
slide32
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

slide33
Birth Weight Status

%

Average birth weights:

Quitters: 6 lbs. 14oz

Smokers: 6 lbs. 8 oz.

*c2 =4.6, p=.04

slide34
Apgar scores by Smoking Outcomes

Birth:

F=2.9;p=.09

5 minutes:

F=4.1;p=.04

slide35
Neonatal Outcomes

by Smoking Status

%

c2=6.2;p=.02

goals for today36
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
rct research questions suggested by stop outcomes
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
incentives co monitoring guesses as to mechanisms of action
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
2 x 2 research design
2 x 2 research design

Incentives

Y

N

CO

+

incentives

CO

only

Y

CO monitoring

Incentives

only

Usual

care

N

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