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    1. Welcome To Counseling For Prenatal Smoking Cessation In the Reproductive Health Care Setting Provided by Development Systems Inc. and the Missouri Department of Health

    2. Additional Information Regarding the Smoking Cessation Training Program The training manual and course was supported by Grant/Cooperative Agreement # UT&/CCU713702-05 from the Center for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

    3. Training Objectives Be able to explain how stopping smoking is one of the preventive measures likely to have a substantial impact on pregnancy outcomes. Be able to discuss how this pregnancy specific, material, can significantly increase rates of cessation among pregnant smokers. Be able to demonstrate smoking cessation counseling.

    4. Topics To Be Covered In The Course History of prenatal smoking cessation courses and their effectiveness Statistics regarding smoking cessation and child and reproductive health General counseling information Theoretical basis for smoking cessation - transtheoretical model and its application Assessing an individuals dependence and need for counseling Smoking cessation counseling format Useful tools for providers Service provider office concerns Client resources -- immediate, local area, national level

    5. Introductions Pair up with someone you dont know or dont know well. Get the following information about them: Name Agency / Position Hold Why are they in the training & what do they hope to gain. One thing that they want to share about themselves that doesnt deal with work (I.e. Family, Pets, Hobbies etc.).

    6. Why Prenatal Smoking Cessation Counselingis Important Legal Perspective

    7. Reasons for Conducting Prenatal Smoking Cessation Counseling According to Missouri State Law: All prenatal care providers must assess pregnant women for the risk and current use of alcohol, tobacco and other substances. All prenatal care providers must provide education regarding the effects of smoking on pregnant women and their fetus. Guidelines Refer to ACOG information

    8. Additional Information To Take Into Consideration Before Beginning Counseling

    9. Cultural Competence Issues Characteristics of Cultural Competence Include: An awareness of ones own cultural values, norms and beliefs An awareness and acceptance of the differences in cultural values, norms and beliefs Broad based knowledge of other cultures The ability to interact successfully in different cultural settings and with diverse cultural groups Knowledge of ones own limitations in interacting with individuals from other cultural backgrounds.

    10. Historical Information on Smoking Cessation and Womens Reproductive Health and Pregnancy Outcomes

    12. Prenatal Smoking Cessation Historical Information Incidence of low birth weight decreased due to smoking cessation. Prenatal smoking cessation interventions increase rates of smoking cessation during pregnancy. Am. Journal of Obstetric Gynecology, Vol. 1, #5, pg. 1328 1334 Physician/nurse midwives are effective as change agents for smoking pregnant women. 15 minute one on one smoking cessation sessions accepted better by patients than most other methods of non-pharmaceutical cessation. Health Education Research: Theory and Practice, Vol. 13, no. 3, pg. 413-438

    13. Effects of Tobacco During Pregnancy Difficulty Conceiving Ectopic & Tubal Pregnancies Poor Weight Gain Chronic Fetal Hypoxia Vaginal Bleeding Premature rupture of vaginal membranes Placenta Previa (2X) Abruptio Placentae (1.5X) Preterm Labor Spontaneous Abortion (20% Greater in smokers than non-smokers)

    14. Effects on Newborns Premature Birth Intrauterine Growth Retardation Smaller Head Circumference Sudden Infant Death Syndrome (SIDS) Cleft Palate/Lip, Eye and Ear Malformations Hernias Congenital Heart Defects Central Nervous System Abnormalities Poor habituation to sound Changes in brain neurochemistry Tremors Behavior regulation problems

    15. Effects on Growing Child More Respiratory Illnesses Diminished Lung Function Chronic Otitis Media Childhood Cancer Impaired Cognitive Abilities Diminished reading, verbal and math skills Lower IQ Poorer social skills and behavior regulation problems Changes in Brain Neurochemistry

    16. Economic Impact of Smoking & Pregnancy Overall costs related to smoking are between $135 to $167 million Costs based on placenta previa, abruptio placenta, PPROM and pre-eclampsia associated with delivery. Smoking cessation interventions during pregnancy shown to decrease overall costs of pregnancy and care after delivery. American Journal of Preventive Med. Volume 15, num.. 3, pg. 212-218

    17. CDC: Smoking Prevalence Among Reproductive-aged Women In 1965, 33% of all U.S. Women smoked. In 1992, 14.3 million aged 18-44 years were smokers (26.9%). From 1987-1990, prevalence declined 3.7%, from 29.6% to 26.9%. In Missouri, the overall rate of female smoking is 26%; of women aged 18-44, 33% are smokers.

    18. CDC: Smoking Prevalence and Level of Education Prevalence inversely related to level of education. Highest rates among women with less than a high school education (40.2% in 1992, but down from 46.5% in 1987).

    19. Smoking Cessation During Pregnancy Stopping smoking is one of the few preventive measures likely to have a substantial impact on pregnancy outcomes.

    20. Smoking Cessation During Pregnancy Pregnant smokers who stop smoking at any time up to the 30th week of gestation have infants with higher birth weight than women who smoke throughout their pregnancy. Pregnant women who stop smoking before the 16th week have infants with birth weights similar to those of babies whose mothers never smoked.

    21. Smoking Cessation During Pregnancy Reductions in cigarette smoking documented by decrease in cotinineor other biologic markers, or by self report, have been associated with an increase in birth weight.

    22. Smoking Cessation During Pregnancy Smoking cessation can also result in a permanent change in life-style that will reduce the risk of smoking-related chronic diseases. This life-style change can also be the framework on which other successful behavior changes can be based.

    23. 23 Who Needs Cessation Counseling & When Is It Best To Approach a Pregnant Woman

    24. Assessing Physical Dependence Smokes within 30 minutes after waking? Has difficulty in places where smoking is not allowed? Find first cigarette of day is the most satisfying one? Smokes 3-5 cigarettes a day? Smokes more in morning? Smokes even when ill? Inhales?

    25. Opportunities for Counseling : Teachable Moments 1st trimester Opportunities During each prenatal visit Informing a woman of positive pregnancy test results Discussing ways to decrease morning sickness Ultrasound First visit w/ partner (if he smokes) Reviewing medical and social history (problems in earlier pregnancies may make her feel vulnerable and more open) Points to reinforce w/ client Its never too late to quit Quitting completely is best but cutting back is better than continued regular smoking Smoking increases the risk of miscarriage Secondhand smoke may harm the fetus too Having had a healthy baby despite smoking in the past does not guarantee the same this time Smoking cessation before the 16th week of pregnancy increases outcomes of a healthy baby

    26. Opportunities for Counseling: Teachable Moments 2nd trimester Opportunities During each prenatal visit Hearing the babys heartbeat for the first time Ultrasound When checking for signs of intrauterine growth During nutritional counseling Points to reinforce Its never too late to quit The development of the baby is taking place very quickly, so the mother needs to keep herself healthy. Quitting smoking reduces the chances of having a low birth weight baby Smoking decreases the amount of blood, oxygen and nutrients flowing to the fetus while exercise increases them Secondhand smoke affects the fetus Quitting completely is best but cutting back is better than continued regular smoking

    27. Opportunities for Counseling: Teachable Moments 3rd trimester Opportunities During each prenatal visit & when checking for signs of intrauterine growth Childbirth classes Hospital visits Labor and delivery (in smoke-free hospital) Phasing into post-partum counseling Points to reinforce Its never to late to quit; quitting even right before birth provides more oxygen and nutrients to the baby, and decreases excessive risk of still birth Nutritional needs are more important due to the rapid growth of the baby Children whose parents smoke are more likely to develop certain sicknesses

    28. Opportunities for Counseling : Teachable Moments Post-partum Opportunities Any telephone contacts or home visits Post-partum exam Well-baby visits Family planning appointments Child immunizations Parenting classes Hospital (post-partum unit) Points to reinforce If woman was able to quit during pregnancy: Stress the importance of staying smoke free for her baby, other children in the house and herself Work with her to continue her exercise and diet plan Praise her efforts to remain smoke-free during pregnancy If she was able to cut down during pregnancy: Get her to enter the next stage of quitting smoking Use exercise and diet to return to prepregnancy weight If the woman still smokes: Counsel her not to smoke in areas where the baby will be placed

    29. Behavior Change Model for Use in Prenatal Smoking Cessation

    30. Frame Work for Smoking Cessation: Behavioral Stages of Change Model Precontemplation Contemplation Planning Action Maintenance/Relapse

    31. Why Stages of Change? Behavior change is an ongoing process -- rarely does it spontaneously occur. Persons at different stages of need, therefore, use different behavior change strategies. Not all persons are equally ready to change, therefore counseling should be tailored to the individual. Movement from one stage to the next may be as important as the actual behavior change.

    32. What Is Going on During The PRECONTEMPLATION Stage Client does not have any idea that change is needed . Education, primarily if the person is in precontemplation stage. Key -- get the person thinking about what if or, I didnt know that could happen.

    33. Possible Outcomes for Women Who Smoke: Fertility effects and birth outcomes Cardiovascular disease Complications with oral contraceptive (OC) use Cervical cancer Early menopause/aggravated symptoms Osteoporosis Slow healing of fractures Lung cancer

    34. Contemplation & Planning/preparation: Patient & Provider Interactions Patient needs support to move to planning and action (family, friends, provider, etc.) Provider provides support to attempt cessation. Provider helps client recognize support structures already in place. Provider helps patient to develop effective cessation strategies.

    35. READY FOR ACTION Patient & Provider Interactions Client needs support to pick a quit date (best when change is already taking place, new job, home, etc). Provider needs to provide encouragement to set the begin change date. Provider needs to emphasize that change can take time and is a process which needs constant reevaluation and modification based on successes not failures.

    36. What Factors Motivate Patient to PLAN and ACT? Cost/benefit to person What social interaction do they lose? What feelings do they lose? What do they gain? How much money do they save? Acute illness (asthma, etc.) Media campaigns (Reinforcing cessation messages) Social pressure Not accepted by most people currently Cessation events Classes, courses, national campaigns Clinician advises to quit Most adults look to their primary care provider for advice -- particularly older women

    37. Withdrawal Symptoms Increased anger, aggression, hostility Loss of social cooperation Emotional imbalance Impaired psychomotor and cognitive functions Cravings Depression Restlessness Anxiety/Tension Impatience Irritability Excessive Hunger Fatigue Headaches Tremors Insomnia

    38. Possible Cessation Strategies To Pick From For Action Stage Whatever the method, let client choose what they believe they can do and have success with!!!!!! Cold turkey white knuckle method Taper down Behavior-focused group cessation Nicotine replacement Acupuncture/hypnosis/alternative strategies

    39. Smoking Cessation Pharmacological Methods Pharmacological methods are primarily used in pre-conceptual service and with post-partum(non-breast feeding) mothers. The effects of these therapies during pregnancy are unknown at this time. Nicotine replacement therapy (NRT). Buproprion/zyban etc.

    40. MAINTENANCE/RELAPSE Client Provider Interactions Often times the maintenance stage, although the longest, is the least addressed! Client needs help to stay smoking free. Provider needs to emphasize relapse prevention skills -- Trigger recognition and differences between successes and relapse times. Provider needs to give the client permission to ask for continued support without feeling guilty or judged.

    41. MAINTENANCE/RELAPSE Resources for Short-term Success Nicotine replacement Telephone hotlines Self-help programs Provider follow-up

    42. MAINTENANCE/RELAPSE Resources for Long-term Success Maintenance components of cessation programs --provider consistency is the key. Environmental restrictions on smoking -- reinforces current non-smoking behaviors. Social norms -- current trends in societys views of smoking.

    43. Learning From RELAPSE When did it happen? What was different from when you werent smoking? What were you doing? What was different from when you werent smoking? Where did the first cigarette come from? (Friend, family member, did you purchase?) Did you use a cessation aid? Will you set another quit date? Is there a better time when you think you can go longer without smoking?

    44. Counseling Help Tools

    45. Basic Counseling Tools Orient client to the session and build rapport. Open ended questioning Who, what, when, where, how? Occasionally can use non-accusatory why questions Attending skills Full attention, verbal and non-verbal given to client Offer options, not directives Provide multiple possibilities regarding change Give information simply Avoid extensive medical terminology Avoid jargon Does the client want facts or need emotional reinforcement Summarizing and closure Restate any agreements or plans regarding stop date

    46. Smoking Cessation During Pregnancy 5-15 Minute Counseling Session (Also Refer to the 5as) Determine clients current smoking status . Review smoking-associated risks to fetus, infant and mother. Review costs/benefits to cessation and how to maintain current non-smoking behaviors. Provide self-help manual or pamphlet. Note smoking status in chart. Review status throughout pregnancy and support any positive changes the patient has made.

    47. Behavior Change Model

    48. Behavior Change Model

    49. 5 As for Providers-- A Counseling Tool Based on The Stages of Change Model ASK/ASSESS about smoking at every opportunity -- reinforce non-smoking behaviors Determine current level of smoking Smoking patterns of family members Past attempts to quit smoking Current stage in the change model ADVISE/EDUCATE all smokers to stop and reinforce positive stop smoking messages Clear message to quit Effects of smoking on mother and child Health benefits of quitting ASSIST the patient in stopping -- help the patient through the contemplation, preparation and action stages of changes ARRANGE follow-up visits -- for reinforcement of behavior changes and modification to plan if necessary

    50. A- ASK/ASSESS Assess clients current level of smoking Ask: When have thought about quitting in the past or since you found out youre pregnant? When was the last time you had a cigarette? How many cigarettes did you smoke yesterday? Why do you think it would be a good idea to quit? What has kept you from quitting in the past? What do you know about how smoking effects both you and your baby? Assess/ask about smoking patterns in her family Assess/ask about any past attempts to quit smoking or cut down Ask: Although you may feel that you failed, you were just practicing quitting. You actually increase your chances of remaining an ex-smoker with each try What caused you to start smoking last time? What could you do instead of smoking the next time this happens?

    51. A- ASK/ASSESS (Continued) Identify her current state in the quitting process: Precontemplation Contemplation Preparation Action Maintenance / relapse Record accurate history of smoking cessation patterns

    52. A-ADVISE Give the client a clear message to quit I strongly advise all of our pregnant smokers to quit. Your baby will get more food and oxygen to grow better and you will feel more energetic now and after the baby is born. Discuss the health benefits of quitting See reference materials for information Discuss the effects of smoking on both the smoker and children

    53. A-ASSIST If she is in the precontemplation stage: (little or no interest in quitting) Help her begin to think of reasons why she might want to quit smoking sometime in the future Ask What have you heard about quitting? Do you know anyone who has quit? What are your concerns or questions about quitting? If she is willing, brainstorm reasons why she should quit for herself and her baby Emphasize social, economic, and health benefits rather than negative health effects If she is in the contemplation, preparation or action stage: (thinking about quitting or ready to quit in the near future) Inform her of the health benefits of not-smoking Help her find ways to deal with the barriers that keep her from quitting. Help her set a quit date

    54. A-ASSIST (Continued) Respond to specific concerns she may have: Concern: Response: Stress: Pregnancy can be a stressful time. If youre worried about not having cigarettes to relieve your stress, lets think about other ways you can deal with stress. What else has worked for you in the past? Others smoking around the client: How can you ask your family/friends not to smoke near you or to go outside and smoke since their smoke can harm the baby? How do you think they would react? Weight gain: Not all women gain weight when they quit smoking. And a little weight gain is normal during pregnancy. Withdrawal symptoms: Not all smokers have withdrawal symptoms- also called signs of recovery. If you have any symptoms, they will lessen over time.

    55. A-ASSIST (Continued) If she is ready to quit: Give her current written materials Explain: most successful quitters had a plan to help them quit. Lets go over these 8 simple steps so you can make your own quitting plan What are your reasons for quitting? When and where do you smoke? List three daily habits associated with smoking you can change Choose three cigarette substitutes you would like to use: Deep breathe Drink water Do something else Discuss/talk with a friend or family member Delay smoking List how you will treat yourself with the cigarette money youve saved List people you can ask to support your efforts to quit smoking (give her the number and first step hotline at 1-800-367-2229) Make a contract with yourself: starting on quit day, you will not beg, bum or borrow anyone elses cigarettes. If you decide to smoke, you will buy and smoke your own cigarettes Set a quit date If she has been able to cut down: Say: Its great that you were able to cut down. Lets work toward the day you can stop smoking completely. Now, lets set a schedule for next week -- how many cigarettes will you smoke a day and when? I think your efforts to cut down have been great, congratulations.

    56. A-ASSIST (Continued) If she is in the maintenance stage: (has already quit) Ask about long term plans regarding smoking What are your plans regarding smoking once your baby is born? Be aware many women take pregnancy pauses in smoking!!!! Help her refine her list of coping strategies Stress Support structures Smoking friends and/or family Talk to her about after the baby is born Cigarette temptation Weight Breast feeding If she is feeling angry or sad You might say: this feeling is normal. Many smokers state that they feel this way after quitting. Smoking was an important part of your life and you feel a loss when it is gone If she wants to try just one You might say: Dont test yourself. Most people who try a cigarette or two go back to smoking. Youve worked so hard to get this far, you can do it!!!! REMEMBER NICOTINE IS ADDICTIVE AND IT MAY BE HARDER TO STOP ONCE YOUVE TRIED JUST ONE.

    57. A-ASSIST (Continued) If she is in relapse stage: (had a few cigarettes or has gone back to smoking) Help her stop the relapse and get back to trying to quit. What you might say: youve just had a slip. Dont worry about the few youve smoked, youve been smoke free for _____ amount of time - you can do it again. If she has relapsed completely, help her get back into the quitting process again move her into the action stage quickly. Stress the progress she has made and refine her quit plan. Remind her about multiple attempts before quitting - each time she will get farther. Get her to explain why she is trying to quit to begin with -- health benefits to her and the baby.

    58. A-ARRANGE Arrange follow-up If she is not ready to quit Understanding of quitting being a hard and difficult decision. Have client think about it and discuss at next visit. If she has agreed to try to quit smoking Make a note -- give additional materials provide support phone #s. Explain you will discuss how she is doing at next visit. If she has already quit smoking Make a note to continue dialogue about her not smoking at next visit to discover any relapse or areas of resistance.

    59. Behavior Change Model

    60. Helpful Cessation Checklist for Health Care Setting Designate a smoking cessation coordinator Create smoke-free office Identify all patients who smoke Have self-help materials on hand Develop an intervention and follow-up protocol

    61. Office Systems for Tracking Client Progress Flow charts/smoking history (reviewed by provider and client -- can be used as a reinforcement for a clients behavior changes) Provider reminder/chart sticker Client reminder

    62. GOING to ASmoke FREE Office Develop a policy & set the date Communicate with staff and clients Post no smoking signs Remove ashtrays Display tobacco education materials Follow-up

    63. Locating Smoking Cessation Referral Resources- National and Local American Lung Association freedom from smoking American Cancer Association fresh start Community Hospitals/HMOs 1-800-4-CANCER

    64. Counseling Concerns Can I really make a difference? Yes! The counselor can provide the smoker with the encouragement and support they need to progress through the stages of quitting. A helping hand can most definitely make a world of difference to someone who is changing life long habits. I do not have time to learn how to counsel. The information in the packet will give you enough information so you feel knowledgeable and comfortable with counseling smokers to quit. Assess/Ask, Advise, Assist and Arrange are the 5 A's method used to help your client become smoke free. Who should do this counseling? Counseling is most successful when the team approach is used. The more people who participate in the counseling the better the outcome will be. Using a combination of person-to-person counseling, written materials and follow-up telephone contacts have been found to be the most effective approach. Can providers who smoke or have never smoked counsel effectively? If you have not smoked before, be prepared to answer questions concerning your expertise on the challenges of quitting smoking. Try to share other ex-smokers experiences. If you do smoke and feel uncomfortable counseling, the client may not feel your are a credible source so you probably will not be an effective counselor. You should not counsel if you do not feel you can make an impact.

    65. Counseling Concerns Smokers often resist counseling. What can I do? Do not push the woman beyond what she is willing to discuss. Concerns about previous quitting attempts or making a plan to quit should be addressed immediately. Quitting smoking involves physical and psychological addiction so you must be there for their support. What if the smoker has other unhealthy behaviors? Give her all appropriate health information and help her set her own priorities. How do I find time to counsel smokers? Counseling sessions as brief as three to ten minutes can be effective. Incorporate your smoking cessation counseling when doing history, physical exam or routine guidance. Every interaction has an impact on the smoker even if there is not time to provide materials or have a discussion. Where do I begin? You already have. Reading this guide is the first step. You must first assess the current level of smoking, family-smoking patterns, past attempts to quitting and current stage of quitting. Advising and educating your client on health consequences of smoking, the benefits of quitting, and the effects of smoking on children and the mother would then be the next step. You then must assist in the stages of change. Arrange a follow-up to evaluate the counseling process.

    66. Identifying Counseling: Observations and Techniques Observing Non-verbal Cues Turning Body Away Playing with Objects No Eye Contact Long Silence Between Responses Pacing Rocking Intense Gestures Towards Counselor Intense Facial Grimacing Observing Verbal Cues Quick Denial Hostile Inconsistency Jokes Out of Context Changes Pace Blames Others Angry Refuses To Answer Terminates Counseling Effective Non-Verbal Techniques Technique Effective Use Physical Proximity Arms Length Voice Tone and Speed Soft, Soothing, Slow Posture Lean Forward, Relax Facial Expression Smiling, Interested Mannerisms/Gestures Open, Welcoming Touching Soft and Discreet Furniture/Physical Setting No Barriers, Moderate Temp etc.

    67. SUGGESTIONS: Reaching Pregnant Smokers Points to Ponder Before Beginning to Counsel Pregnancy is the ideal time to counsel smokers to quit. Women are often motivated to quit to protect the health of their unborn babies. However, it is important to address the benefits of quitting for both the mother and the baby. Otherwise, the mother may be able to quit during pregnancy but is likely to resume smoking after the baby is born. Some women who smoked during an earlier pregnancy may already have a healthy baby/child or may have friends who smoked during their pregnancies and have healthy babies. Since all pregnancies are different, emphasize that she increases her chances of having a healthy baby this time if she stops smoking. NOTE: Currently, use of the nicotine replacement therapy (patch or gum) is not recommended for pregnant (or breastfeeding women).

    68. SUGGESTIONS: Reaching Pregnant Smokers Counsel From Your HEART as Well as Your Head 1. Take time to build rapport. Be warm, friendly and caring. Show respect for the woman and what she says and feels. Find out what the clients values and needs are. Be concrete and specific in your responses. 2. Be positive and non-judgmental. Some women fear you may criticize and lecture them about smoking. Acknowledge that it is not easy to quit but encourage her that she will be able to quit smoking and that you have confidence in the ability to do this. Suggest she talk to ex-smokers about how they quit. If she has tried to quit before, focus on the positive aspects of her previous practice quit attempts rather than on her feelings of failure. 3. Focus on other positive lifestyle changes she has made (losing weight, wearing a seatbelt or healthy eating) to build her confidence. Smokers who believe they can quit are the ones who succeed. 4. Focus on the womans feelings and behavior. Every pregnant woman has some worries about her pregnancy, her bodily changes, and fatigue. Allow her to discuss her concerns and reassure her that such feelings are normal. 5. Remember that stressful situations in a womans home or work life (like violence, harassment, etc) may contribute to why she smokes or why she finds it hard to quit. 6. Encourage support from others. Ask her to identify family members and friends who can help her stop smoking. Together, brainstorm ways to ask for help. Discuss whether her partner or close friends smoke. If they do, talk about things they can do to help her, like not smoking around her or quitting also. If she has no other support, you may want to offer yourself as a support person.

    69. KEY POINTS:Counseling Women Who Smoke Counseling is most effective when you join with the woman as her partner to develop a personalized quitting plan. Having a plan is the critical component in successful quitting. Assess how ready each woman is to quit and tailor your counseling accordingly. Problem-solve together to break down each womans barriers to quitting. Listen well. Help her come up with her own answers rather than imposing your ideas. Quitting is a process that may occur over a number of quit attempts. View these attempts as practice where she learns what her triggers are and what coping strategies work (or dont work). Women are most likely to succeed when they believe they can successfully quit or cut down. Your confidence in each womans ability to quit successfully will increase her confidence in herself.

    70. KEY POINTS:Counseling Women Who Smoke Most women know that smoking is bad for them but they need support. Women place a high value on a personalized, one-on-one approach to receiving new information. They prefer receiving advice to stop smoking if it is provided in a caring, personal way by someone who offers support, avoids blame and guilt, and addresses their personal needs. It is important to take time to develop rapport and put each woman at ease. Use a conversational tone of voice, establish eye contact, sit next to her, and smile. Women with a lower educational level, who lack support, or who live with a smoker may have the most difficulty quitting. Regardless of whether a woman is pregnant, a new mother, or thinking about pregnancy, there are health benefits for both her and her baby/children when she quits smoking.