Using the 5As

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Using the 5As
SIDS Mid-Atlantic presents
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SIDS Mid-Atlantic

• 2700 S. Quincy St. Suite 220
• Arlington VA 22206
• 703-933-9100
• www.sidsma.org
• sidsma27_at_aol.com
• Betty Connal, RN, MS, Director

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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 As 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

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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

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Agenda

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

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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

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Risks of Smoking

• Placenta previa
• Miscarriage
• Ectopic pregnancy
• Preterm Premature Rupture Of Membranes
• Abruptio placenta

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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

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Smoking effects on the baby

• Otitis media (ear infections)
• Asthma
• Bronchitis and pneumonia
• Wheezing and lower respiratory illness

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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

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Risk factors for premature birth

• multifetal pregnancytwins, triplets and more
• maternal age (35 years)
• black race
• low SES
• unmarried
• previous fetal or neonatal death
• 3 spontaneous terminations
• uterine abnormalities
• incompetent cervix
• genetic predisposition

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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

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Signs of Premature Labor

• Contractions every 10 minutes or more
• Changes in vaginal discharge (leaking fluid or
  blood from vagina)
• Pelvic pressurebaby pushing down
• Low dull backache
• Cramps that feel like a period
• Abdominal cramps with or without diarrhea

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Why use the Five As?

• About 35 of women will quit smoking during
  pregnancy, benefiting themselves, their next
  pregnancy, their children and their families

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Cost of Complicated Births

• Smokers average cost of birth 11,000
• Non smokers average cost of birth 6500

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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

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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
72 hours Breathing is easier bronchial tubes
relax energy levels increase
15 years Heart attack risk same as for someone
who never smoked
1990 Surgeon Generals Report
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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

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The 5A approach

• Ask about patients habits.
• Advise of consequence of smoking.
• Assess willingness to quit.
• Assist with cessation plan development.
• Arrange for follow-up

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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)

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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.

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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.

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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 patients concerns.

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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.

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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.

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Advise example for recent non-smoker

• Ms. Smith, I want to congratulate you on making
  such an important decision for your babys
  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.

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Three patient types

• Current smoker who wants to quit.
• Recent non-smoker
• Current smoker who does not want to quit.

Target of Assess step
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Assess Decision Flow
Provide appropriate cessation techniques (Step 4
of 5A approach)
Yes
Yes
No
Provide motivational materials and counseling
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Assess Decision Flow (cont)
Assist with cessation maintenance (Step 4 of 5A
approach)
Yes
No
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Dealing with the resistant patient

• Find out why patient doesnt want to quit.
• Emphasize risks of smoking.
• Point out the rewards of quitting.
• Discuss roadblocks and ways to overcome them.

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Patients Who Decline to Quit Using the 5 Rs
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Assist

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

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Assist (cont)

• Roadblocks
• Friends all smoke
• Doesnt really want to quit but feels should quit
  
• Rewards
• Clothes and breath will smell better
• Cough will go away

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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 theres
  smoke

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Assist Coping Strategies (cont)

• Roadblocks
• Friends all smoke/Talk on phone instead of in
  person
• Doesnt 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

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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.

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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.

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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?

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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)

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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

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Great Start 1-866-66StartInteractive Quitline
for Pregnant Smokers
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Resources

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

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Virginia Quit Line

• 1-800-QUIT NOW