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S MOKING C ESSATION I N P REGNANCY. 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

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slide1

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/

slide2

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: Women and Smoking(Surgeon General’s Report on Women and Smoking, 2001)
slide4
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
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)
slide8

Tobacco Use During Pregnancy

  • 8.0% of women use tobacco during pregnancy (general population)
    • (Maryland Vital Statistics, 2002)
  • 25% of women use tobacco during pregnancy (health dept. population)

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

profile the pregnant smoker
Profile: The Pregnant Smoker

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

  • 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
factors influencing smoking among women 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 effects women 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

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

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

Long-term Maternal Effects(Women and Smoking: A Report of the Surgeon General-2001)
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

Health Effects on Fetus

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

health effects on children environmental tobacco smoke
Sudden Infant Death Syndrome (SIDS)

Respiratory tract infections

Colds

Ear infections

Reduced lung function

Diabetes

Asthma

Pneumonia and Bronchitis

Childhood and adult cancers

ADHD

Increased likelihood of becoming smokers

Health Effects On Children(Environmental Tobacco Smoke)

(American Lung Association, 2001)

why is pregnancy is an ideal time to quit smoking sprauve 1999
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%
slide16

SMOKING CESSATION

IN PREGNANCY

(SCIP)

scip history
SCIP History

When: 1988 by a federal grant

What: A smoking cessationintervention 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
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
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)
slide20

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

Maryland’s Health Improvement Plan, 2001

scip objectives
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
Elements of SCIP

Element #1

  • Patient Self-help Materials
    • Quit & Be Free Client Manual
    • Quit Kit
quit kit
Quit Kit

Baby Shirt

Toothbrush/Toothpaste

Cinnamon Sticks

Pen

Paper Clips

RubberBands

Relaxation Tape

element 2
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
slide26

5 A’s

ASK

ADVISE

ASSESS

ASSIST

ARRANGE

1 ask
#1 ASK

client about tobacco use...

  • Identify and document smoking status for every client at each visit
slide28

#2ADVISE

client of…

  • Health hazards of smoking
  • Benefits of quitting
  • Need for change–given in a non-authoritarian and supportive style
3 assess
#3ASSESS

client’s readiness to quit stage…

  • Asking open-ended questions
  • Eliciting self-motivational statements
  • Listening Reflectively (listening with empathy)
  • Affirming the client
  • Summarizing
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

#4ASSIST

client in making a quit attempt...

5 arrange
#5ARRANGE

follow-up with client...

  • 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 appointment
  • Follow-up phone call in two weeks
slide33

STAGES OF CHANGE

(adapted from DiClemente and Prochaska)

Client enters

Patient will incorporate change into daily lifestyle

Patient not interested changing

Stage I

Pre-

contemplation

client exits

Stage V

Maintenance

Stage II

Contemplation

Stage IV

Action

Patient will take decisive action

Patient will examine benefits & barriers to change

Stage III

Preparation

Patient will discover elements necessary for decisive action

stages of change prochaska and diclemente 1983
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
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
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
Stages of Change and Opportunities for Health Professionals (cont.)
  • Maintenance
    • Continue reinforcement
    • Ask what strategies have been helpful and what situations problematic
slide38

5 A’s

ASK

Smoking status

ADVISE

  • Health effects
  • Need for change

Readiness to quit

ASSESS

ASSIST

In quitting

ARRANGE

  • Follow-up
  • Documentation
  • phone call (2 wks.)
motivational interviewing m i rollnick s miller w r 1995
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
Five Principles of M.I.

1. Express Empathy

2. Develop Discrepancy

3. Avoid Argumentation

4. Roll with Resistance

5. Support Self-Efficacy

slide41

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
slide42

2. Develop Discrepancy

  • Motivate discrepancy in the patient
    • (where the patient wants to be
  • v.
  • where they are right now)
  • Patient should present arguments for change
slide43

3. Avoid Argumentation

  • Keep patient resistance levels LOW
    • More resistance = Less likely to change
  • “Denial is not a problem of patient personality,
        • but of therapist skill”
slide44

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)
slide45

5. Support

Self-Efficacy

  • Impart belief about possibility of change
  • Remember it isalwaysthe patient’s choice whether or not to change
slide46

5 A’s

ASK

Smoking status

ADVISE

  • Health effects
  • Need for change

Readiness to quit

ASSESS

ASSIST

In quitting

ARRANGE

  • Follow-up
  • Documentation
  • phone call (2 wks.)
slide47

Element #3

  • Documentation & Follow-up
arrive in style goals
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
Arrive in Style Teen Intervention

Elements:

1. Full color magazine

2. Brief counseling intervention

3. Documentation

4. Evaluation card

arrive in style counseling intervention
Arrive in StyleCounseling Intervention
  • ASK client about tobacco use
  • ADVISEof harmful effects, benefits of quitting, the need for change
  • ASSESS readiness to quit stage
  • ASSISTin making a quit attempt
  • ARRANGE next appointment
    • Summarize what actions client has agreed to do before next visit
    • Follow-up phone call in two weeks
counseling teens
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
review
Review

Elements:

SCIPTeen 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

slide55

5 A’s

ASK

Smoking status

ADVISE

  • Health effects
  • Need for change

Readiness to quit

ASSESS

ASSIST

In quitting

ARRANGE

  • Follow-up
  • Documentation
  • phone call (2 wks.)