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SMOKING CESSATION IN PREGNANCY Department of Health and Mental Hygiene Center for Health Promotion, Education and Tobacco Use Prevention

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Presentation on theme: "SMOKING CESSATION IN PREGNANCY Department of Health and Mental Hygiene Center for Health Promotion, Education and Tobacco Use Prevention"— Presentation transcript:

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2 SMOKING CESSATION IN PREGNANCY Department of Health and Mental Hygiene Center for Health Promotion, Education and Tobacco Use Prevention http://www.fha.state.md.us/ohpetup/

3 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

4 US Facts: Women and Smoking (Surgeon General’s Report on Women and Smoking, 2001) 22% of women 18 + years smoke 15% of female 8 th graders smoke 30% of female 12 th graders smoke 165,000 + women died from smoking- related diseases in 1999

5 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

6 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)

7 (DHMH, First Annual Tobacco Study, 2002)

8 (DHMH, Initial Findings from the Baseline Tobacco Study, 2000)

9 25% of women use tobacco during pregnancy (health dept. population) (Maryland Prenatal Risk Assessment, 7/00-6/01) 8.0% of women use tobacco during pregnancy (general population) (Maryland Vital Statistics, 2002) Tobacco Use During Pregnancy

10 Profile: The Pregnant Smoker 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 (Women and Smoking: A Report of the Surgeon General-2001)

11 Factors Influencing Smoking Among 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

12 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 During Pregnancy Postpartum

13 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

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

15 Sudden Infant Death Syndrome (SIDS) Respiratory tract infections Colds Ear infections Reduced lung function Diabetes Health Effects On Children (Environmental Tobacco Smoke) Asthma Pneumonia and Bronchitis Childhood and adult cancers ADHD Increased likelihood of becoming smokers (American Lung Association, 2001)

16 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%

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18 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.

19 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

20 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)

21 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

22 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

23 Elements of SCIP  Patient Self-help Materials –Quit & Be Free Client Manual –Quit Kit Element #1

24 Manual

25 Quit Kit Toothbrush/Toothpaste Relaxation Tape Paper Clips Baby Shirt Pen Cinnamon Sticks Rubber Bands

26 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

27 ASK ADVISE ASSESS ARRANGE ASSIST 5 A’s

28 #1 ASK  Identify and document smoking status for every client at each visit client about tobacco use...

29 #2 ADVISE  Need for change – given in a non- authoritarian and supportive style client of…  Health hazards of smoking  Benefits of quitting

30 #3 ASSESS  Asking open-ended questions  Eliciting self-motivational statements  Listening Reflectively (listening with empathy)  Affirming the client  Summarizing client’s readiness to quit stage…

31 #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 client in making a quit attempt...

32 #5 ARRANGE  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 follow-up with client...

33 5 A’s

34 Stage I Pre- contemplation Stage II Contemplation Stage III Preparation Stage IV Action Stage V Maintenance STAGES OF CHANGE (adapted from DiClemente and Prochaska) Patient not interested changing Patient will examine benefits & barriers to change Patient will incorporate change into daily lifestyle Patient will take decisive action Patient will discover elements necessary for decisive action Client enters client exits

35 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

36 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

37 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

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

39 Readiness to quit Follow-up Documentation phone call (2 wks.) ASK ADVISE ASSESS ARRANGE In quitting ASSIST Health effects Need for change 5 A’s Smoking status

40 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.”

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

42 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

43 2. Develop Discrepancy Patient should present arguments for change Motivate discrepancy in the patient ( where the patient wants to be v. where they are right now )

44 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”

45 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)

46 5. Support Self-Efficacy Impart belief about possibility of change Remember it is always the patient’s choice whether or not to change

47 Readiness to quit Follow-up Documentation phone call (2 wks.) ASK ADVISE ASSESS ARRANGE In quitting ASSIST Health effects Need for change 5 A’s Smoking status

48 Element #3 Documentation & Follow-up

49 Arrive in Style Teen Intervention

50 (DHMH, First Annual Tobacco Study, 2002)

51 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

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

53 Arrive in Style Counseling 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

54 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

55 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

56 Readiness to quit Follow-up Documentation phone call (2 wks.) ASK ADVISE ASSESS ARRANGE In quitting ASSIST Health effects Need for change 5 A’s Smoking status


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