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SMOKING CESSATION IN PREGNANCY Department of Health and

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Title: SMOKING CESSATION IN PREGNANCY Department of Health and


1
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/
2
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

3
US Facts Women and Smoking (Surgeon Generals
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

4
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
  • 21.9African American
  • 13.8 Hispanic
  • 11.2 Asian Pacific Islander

5
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)

6
(DHMH, First Annual Tobacco Study, 2002)
7
(DHMH, Initial Findings from the Baseline Tobacco
Study, 2000)
8
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)

9
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 Natl Program Office)
  • 3.8 heavy smokers
  • 25 quit upon learning they are pregnant

10
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

11
Maternal Health EffectsWomen and Smoking A
Report of the Surgeon General-2001)
During Pregnancy
Postpartum
  • Miscarriage
  • Premature birth
  • Ectopic pregnancy
  • Placental abnormalities
  • Bleeding
  • Premature rupture of membranes
  • Impaired lactation
  • Inhibited protection against SIDS from breast milk

12
Long-term Maternal Effects(Women and
Smoking A Report of the Surgeon General-2001)
  • Menstrual abnormalities
  • Earlier menopause
  • Increased risk of osteoporosis
  • Premature aging of the skin
  • Muscular degeneration
  • Decreased life expectancy
  • Heart Disease
  • Cancer
  • Embolism Stroke
  • Emphysema
  • Decreased fertility

13
Health Effects on Fetus
(DHHS, 1990 ACOG, 1997 Smoke-Free Families
National Program Office and ACHS, 1996)
  • Preterm delivery
  • Low Birth Weight
  • Fetal artery constriction
  • Lessened amounts of oxygen and nutrients in the
    fetus
  • Fetal Growth Retardation
  • Small for gestational age
  • Increased fetal heart rate
  • Chronic Fetal Hypoxia
  • Perinatal death

14
Health Effects On Children(Environmental Tobacco
Smoke)
(American Lung Association, 2001)
  • 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

15
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

16
SMOKING CESSATION IN PREGNANCY (SCIP)
17
SCIP History
  • When 1988 by a federal grant
  • What A smoking cessation intervention for
    pregnant smokers
  • How Training of local health department staff
    and managed care organizations to facilitate
    quitting or reducing cigarette consumption among
    pregnant women.


18
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

19
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)

20
IMR and Healthy People 2010 Objectives by Race,
Maryland, Selected Years, 1989-2010, and the U.S.
2010 Objective for All Races
Marylands Health Improvement Plan, 2001
21
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

22
Elements of SCIP
Element 1
  • Patient Self-help Materials
  • Quit Be Free Client Manual
  • Quit Kit

23
Manual
24
Quit Kit
Baby Shirt
Toothbrush/Toothpaste
Cinnamon Sticks
Pen
Paper Clips
Rubber Bands
Relaxation Tape
25
Element 2
  • Brief Counseling Intervention
  • 5 As for Brief Smoking Cessation Counseling for
    Pregnant Women
  • (U.S. Department of Health and Human Services)
  • Ask
  • Advise
  • Assess
  • Assist
  • Arrange

26
5 As
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
27
1 ASK
client about tobacco use...
  • Identify and document smoking status for every
    client at each visit

28
2 ADVISE
client of
  • Health hazards of smoking
  • Benefits of quitting
  • Need for change given in a non-authoritarian
    and supportive style

29
3 ASSESS
clients readiness to quit stage
  • Asking open-ended questions
  • Eliciting self-motivational statements
  • Listening Reflectively (listening with empathy)
  • Affirming the client
  • Summarizing

30
4 ASSIST
client in making a quit attempt...
  • Positively reinforce past attempts to quit
  • Help client to identify barriers and solutions
  • Communicate free choice
  • Give support and confidence in patients 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

31
5 ARRANGE
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

32
5 As
33
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
34
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

35
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

36
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

37
Stages of Change and Opportunities for Health
Professionals (cont.)
  • Maintenance
  • Continue reinforcement
  • Ask what strategies have been helpful and what
    situations problematic

38
5 As
ASK
Smoking status
ADVISE
  • Health effects
  • Need for change

Readiness to quit
ASSESS
ASSIST
In quitting
ARRANGE
  • Follow-up
  • Documentation
  • phone call (2 wks.)

39
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.

40
Five Principles of M.I.
  • 1. Express Empathy
  • 2. Develop Discrepancy
  • 3. Avoid Argumentation
  • 4. Roll with Resistance
  • 5. Support Self-Efficacy

41
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

42
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

43
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
44
4. Roll with Resistance
  • Opposing resistance generally reinforces it
  • DONT PUSH!!!
  • Roll with the momentum with a goal of shifting
    client perceptions
  • (Motivational Enhancement Therapy Manual, Vol. 2,
    1999)

45
5. Support Self-Efficacy
  • Impart belief about possibility of change
  • Remember it is always the patients choice
    whether or not to change

46
5 As
ASK
Smoking status
ADVISE
  • Health effects
  • Need for change

Readiness to quit
ASSESS
ASSIST
In quitting
ARRANGE
  • Follow-up
  • Documentation
  • phone call (2 wks.)

47
  • Element 3
  • Documentation Follow-up

48
Arrive in Style Teen Intervention
49
(DHMH, First Annual Tobacco Study, 2002)
50
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

51
Arrive in Style Teen Intervention
Elements
  • 1. Full color magazine
  • 2. Brief counseling intervention
  • 3. Documentation
  • 4. Evaluation card

52
Arrive in StyleCounseling Intervention
  • ASK client about tobacco use
  • ADVISE of harmful effects, benefits of quitting,
    the need for change
  • ASSESS readiness to quit stage
  • ASSIST in 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

53
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

54
Review
  • Elements
  • SCIP Teen 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

55
5 As
ASK
Smoking status
ADVISE
  • Health effects
  • Need for change

Readiness to quit
ASSESS
ASSIST
In quitting
ARRANGE
  • Follow-up
  • Documentation
  • phone call (2 wks.)
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