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Using the 5A’s. SIDS Mid-Atlantic presents. SIDS Mid-Atlantic . 2700 S. Quincy St. Suite 220 Arlington VA 22206 703-933-9100 www.sidsma.org sidsma27@aol.com Betty Connal, RN, MS, Director . Objectives .

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using the 5a s

Using the 5A’s

SIDS Mid-Atlantic presents

sids mid atlantic
SIDS Mid-Atlantic
  • 2700 S. Quincy St. Suite 220
  • Arlington VA 22206
  • 703-933-9100
  • www.sidsma.org
  • sidsma27@aol.com
  • Betty Connal, RN, MS, Director

Presented by Health Care Education & Training, Inc.

objectives
Objectives
  • To establish evidence-based, best practice prenatal smoking cessation interventions as a routine part of prenatal care by training health care providers in the Five A’s Method of Smoking Cessation
  • To assure that all pregnant women in Virginia are asked about their use of tobacco and that all pregnant smoking women in Virginia receive evidence-based treatments in smoking cessation

Presented by Health Care Education & Training, Inc.

program objectives
Program Objectives
  • Describe the 5A prenatal smoking cessation method
  • Incorporate the 5A prenatal smoking cessation method into the standard protocol
  • Identify readily available smoking cessation resources

Presented by Health Care Education & Training, Inc.

agenda
Agenda
  • Introduction
  • Ask
  • Advise/Assess
  • Assist/Arrange for follow-up
  • Implementation issues and role play
  • Resource identification
  • Wrap-up

Presented by Health Care Education & Training, Inc.

risks of smoking in pregnancy
Risks of Smoking in Pregnancy

Smoking remains the single most important preventable cause of poor birth outcome

  • 20% low birth weight deliveries
  • 8% pre-term births
  • 5% perinatal deaths

Presented by Health Care Education & Training, Inc.

risks of smoking
Risks of Smoking
  • Placenta previa
  • Miscarriage
  • Ectopic pregnancy
  • Preterm Premature Rupture Of Membranes
  • Abruptio placenta

Presented by Health Care Education & Training, Inc.

risks of smoking8
Risks of Smoking
  • Low birth weight
  • Small for gestational age
  • Preterm delivery
  • 3 to 4 times greater risk of Sudden Infant Death Syndrome (SIDS)
  • Stillbirths

Presented by Health Care Education & Training, Inc.

smoking effects on the baby
Smoking effects on the baby
  • Otitis media (ear infections)
  • Asthma
  • Bronchitis and pneumonia
  • Wheezing and lower respiratory illness

Presented by Health Care Education & Training, Inc.

who is at risk for premature birth
Who is at Risk for Premature Birth?
  • The best predictor of having a preterm birth is a history of preterm labor/delivery or prior low birthweight

Presented by Health Care Education & Training, Inc.

risk factors for premature birth
Risk factors for premature birth
  • multifetal pregnancy—twins, triplets and more
  • maternal age (<17 and >35 years)
  • black race
  • low SES
  • unmarried
  • previous fetal or neonatal death
  • 3+ spontaneous terminations
  • uterine abnormalities
  • incompetent cervix
  • genetic predisposition

Presented by Health Care Education & Training, Inc.

risk for premature birth
Risk for premature birth
  • low pre-pregnant weight
  • obesity
  • infections
  • bleeding
  • anemia
  • major stress
  • lack of social supports
  • tobacco use
  • illicit drug use
  • alcohol abuse
  • folic acid deficiency

Presented by Health Care Education & Training, Inc.

signs of premature labor
Signs of Premature Labor
  • Contractions every 10 minutes or more
  • Changes in vaginal discharge (leaking fluid or blood from vagina)
  • Pelvic pressure—baby pushing down
  • Low dull backache
  • Cramps that feel like a period
  • Abdominal cramps with or without diarrhea

Presented by Health Care Education & Training, Inc.

why use the five a s
Why use the Five A’s?
  • About 35% of women will quit smoking during pregnancy, benefiting themselves, their next pregnancy, their children and their families

Presented by Health Care Education & Training, Inc.

cost of complicated births
Cost of Complicated Births
  • Smokers average cost of birth $11,000
  • Non smokers average cost of birth $6500

Presented by Health Care Education & Training, Inc.

cost effectiveness of smoking cessation intervention
Cost Effectiveness of Smoking Cessation Intervention
  • Cost per life year saved, in thousands of dollars
  • Smoking Cessation Intervention $2500
  • Mammography $50,000
  • Treatment of high cholesterol $100,000

Presented by Health Care Education & Training, Inc.

timing of health benefits
Timing of Health Benefits

20 minutes

Blood pressure, heart rate return to normal

2 to 12 weeks

Circulation improves

8 hours

O2 level returns to normal; nicotine and CO levels reduced by half

3 to 9 months

Lung function increases by up to 10%; coughing, wheezing, breathing problems reduced

24 hours

CO is eliminated from body; lungs begin to eliminate mucus, debris

1 year

Heart attack risk halved

48 hours

Nicotine eliminated from body; taste and smell improve

10 years

Lung cancer risk halved

15 years

Heart attack risk same as for someone who never smoked

72 hours

Breathing is easier; bronchial tubes relax; energy levels increase

Presented by Health Care Education & Training, Inc.

1990 Surgeon General’s Report

intervention works
Intervention Works
  • Smoking cessation intervention by clinicians improves quit rates
  • Brief counseling (5 to 15 minutes total) is all that is needed to help many pregnant smokers quit
  • A woman is more likely to quit smoking during pregnancy than at any other time in her life

Presented by Health Care Education & Training, Inc.

the 5a approach
The 5A approach
  • Ask about patient’s habits.
  • Advise of consequence of smoking.
  • Assess willingness to quit.
  • Assist with cessation plan development.
  • Arrange for follow-up

Presented by Health Care Education & Training, Inc.

research
Research

Conclusions

  • Brief cessation counseling session can improve cessation rates as compared to simple advice to quit
  • More intensive counseling has not been documented to increase cessation rates
  • Benefits of brief counseling effective in light to moderate smokers (less than a pack per day)

Presented by Health Care Education & Training, Inc.

slide21
Ask

Goal: Find out if patient smokes or has recently quit.

  • I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime.
  • I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.

Presented by Health Care Education & Training, Inc.

ask cont
Ask (cont)
  • I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.
  • I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant.
  • I smoke regularly now, about the same as BEFORE I found out I was pregnant.

Presented by Health Care Education & Training, Inc.

advise
Advise
  • Goal is to either:

1) present compelling evidence about the importance of quitting

2) encourage recent quitters to continue abstinence.

  • Message must be strong, clear, and relevant to specific patient’s concerns.

Presented by Health Care Education & Training, Inc.

advise examples
Advise Examples
  • Appropriate:

“Ms. Smith, it is important for you to quit smoking. As your Resource Mother, I need you to know that quitting smoking increases your chances of having a healthy baby. Your health will also improve...”

  • Inappropriate:

“Ms. Smith, you need to quit smoking.”

Presented by Health Care Education & Training, Inc.

create an advise statement
Create an Advise Statement
  • Maria is 19-year old woman with two children. She has smoked since she was 16 years old. She has indicated that she smoked with her first two children and “they are fine.”

Presented by Health Care Education & Training, Inc.

advise example for recent non smoker
Advise example for recent non-smoker
  • “Ms. Smith, I want to congratulate you on making such an important decision for your baby’s health. As your nurse, I need you to know that quitting smoking has greatly increased your chances of having a healthy baby. Your health will also improve….”

Presented by Health Care Education & Training, Inc.

three patient types
Three patient types
  • Current smoker who wants to quit.
  • Recent non-smoker
  • Current smoker who does not want to quit.

Target of Assess step

Presented by Health Care Education & Training, Inc.

assess decision flow

Patient willing to quit?

Does patient currently smoke?

Assess Decision Flow

Provide appropriate cessation techniques (Step 4 of 5A approach)

Yes

Yes

No

Provide motivational materials and counseling

Presented by Health Care Education & Training, Inc.

assess decision flow cont

Has patient smoked in the past?

Does patient currently smoke?

Assess Decision Flow (cont)

Assist with cessation maintenance (Step 4 of 5A approach)

No

Yes

Presented by Health Care Education & Training, Inc.

dealing with the resistant patient
Dealing with the resistant patient
  • Find out whypatient doesn’t want to quit.
  • Emphasize risksof smoking.
  • Point out the rewardsof quitting.
  • Discuss roadblocksand ways to overcome them.

Presented by Health Care Education & Training, Inc.

patients who decline to quit using the 5 r s

Relevance

Risks

Rewards

Roadblocks

Repetition

Patients Who Decline to Quit: Using the 5 R’s

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assist
Assist
  • Why people smoke:
      • Addicted to nicotine
      • Enjoyment
  • Common triggers:
      • After eating
      • Social situations

Presented by Health Care Education & Training, Inc.

assist cont
Assist (cont)
  • Roadblocks:
      • Friends all smoke
      • Doesn’t really want to quit but feels should quit
  • Rewards:
      • Clothes and breath will smell better
      • Cough will go away

Presented by Health Care Education & Training, Inc.

assist coping strategies
Assist: Coping Strategies
  • Why people smoke:
      • Addicted to nicotine/Drink lots of water
      • Enjoyment/Do something else enjoyable
  • Common triggers:
      • After eating/Eat breath mint
      • Social situations/Avoid situations where there’s smoke

Presented by Health Care Education & Training, Inc.

assist coping strategies cont
Assist: Coping Strategies (cont)
  • Roadblocks:
      • Friends all smoke/Talk on phone instead of in person
      • Doesn’t really want to quit but feels should quit/Identify personal reasons to quit
  • Rewards:
      • Clothes and breath will smell better/Wash all clothing
      • Cough will go away/Track number of coughing bouts per day

Presented by Health Care Education & Training, Inc.

smoking cessation plan
Smoking Cessation Plan

Step 1. Identify why, common triggers, and major roadblocks.

Step 2. Identify rewards.

Step 3. Establish a quit date.

Step 4. Identify cessation method and coping strategies.

Step 5. Provide resources.

Presented by Health Care Education & Training, Inc.

arrange for follow up
Arrange for follow-up
  • For patient who has remained smoke-free, offer congratulations.
  • For patient who has relapsed, return to Assist step in 5A approach.

Presented by Health Care Education & Training, Inc.

relapse questions
Relapse Questions
  • What was the trigger?
  • When did the relapse occur?
  • What was going on in your life at the time of relapse?
  • Did you have a support person there?
  • What techniques did you try to help you work through the craving?
  • Would you like to set another quit date?

Presented by Health Care Education & Training, Inc.

reimbursement
Reimbursement
  • ICD-9-CM code 305.1 (tobacco use disorder, tobacco dependence)

AND

  • CPT code 99401 (15-minute physician-provided counseling)
    • with modifier 25 as part of regular prenatal visit

OR

  • CPT code 99211 (nurse counseling)

Presented by Health Care Education & Training, Inc.

resources
Resources

SIDS Mid-Atlantic www.sidsma.org

  • Go to ‘Professionals’
  • ‘Stop Smoking Stop SIDS Program’
  • Links to state and national info and resources

March of Dimes www.marchofdimes.com

Presented by Health Care Education & Training, Inc.

great start 1 866 66start interactive quitline for pregnant smokers
Great Start 1-866-66StartInteractive Quitline for Pregnant Smokers

Presented by Health Care Education & Training, Inc.

resources42
Resources
  • Smoke Free Families www.smokefreefamilies.org
  • National Partnership to Help Pregnant Smokers Quit www.helppregnantsmokersquit.org

Presented by Health Care Education & Training, Inc.

virginia quit line
Virginia Quit Line
  • 1-800-QUIT NOW

Presented by Health Care Education & Training, Inc.