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Best Practice Interventions Jolie Person Texas Department of State Health Services.

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1 Best Practice Interventions Jolie Person Texas Department of State Health Services

2   Participants will describe the adverse effects of smoking on the mother, her unborn child, and family.  Participants will discuss the effectiveness of prenatal smoking cessation interventions.  Participants will compare three Best Practice interventions for smoking cessation. Community Health Worker Continuing Education Unit: 1 Competency: 0.5 Knowledge, 0.5 Communication Learner Centered Objectives

3 Video Clip - 25 Ways to Quit Smoking. Bill Plimpton

4   Approximately 13% of women reported smoking during the last 3 months of pregnancy.  Of women who smoked 3 months before pregnancy, 45% quit during pregnancy.  Among women who quit smoking during pregnancy, 50% relapsed within 6 months after delivery. Prevalence of Tobacco Use Pregnancy Risk Assessment Monitoring System (PRAMS)

5   A Smoking Partner  A Large Number Of Children  A High Rate Of Tobacco Consumption  Deficiencies In Prenatal Care Schneider, S., Huy C., Schutz J., & Diehl, K. (2010). Smoking cessation during pregnancy: a systematic literature review. Drug Alcohol Rev, 29. Predictors of Smoking During Pregnancy

6   Tobacco is a plant whose brown-colored leaves are cured and dried. Tobacco may also be classified as a drug.  By definition, a drug is a nonfood substance that can cause changes in the function of the body and/or mind. Tobacco 101

7 Types of Tobacco

8 There are over 4,000 chemicals in tobacco smoke 599 Additives At least 69 of those 4,000 chemicals are known to cause cancer Cancer-Causing Chemicals Formaldehyde: Used to embalm dead bodies Benzene: Found in gasoline Polonium 210: Radioactive and very toxic Vinyl chloride: Used to make pipes Toxic Metals Chromium: Used to make steel Arsenic: Used in pesticides Lead: Once used in paint Cadmium: Used to make batteries Poison Gases Carbon monoxide: Found in car exhausts Hydrogen cyanide: Used in chemical weapons Ammonia: Used in household cleaners Butane: Used in lighter fluid Toluene: Found in paint thinners

9 Secondhand Smoke Mainstream Smoke (smokers inhale about 15% of the smoke from a cigarette) Sidestream Smoke (smoke from the burning end of the cigarette) Responsible for 3,000 lung cancer deaths in non-smokers each year (Source: American Cancer Society)

10   Not a safe substitute for cigarettes  Increases the risk for oral cancer and other health problems  Contains nicotine, the same addictive drug found in cigarettes. Smokeless Tobacco

11 Adverse Effects of Tobacco Use  Frequent colds  Smoker’s Cough  Gastric Ulcers  Chronic Bronchitis  Increase in heart rate and blood pressure  Hardening of the arteries  Gum disease, recession  Emphysema  Heart Disease  Stroke  Cancer  Premature aging  Delayed wound healing  Risk of developing Type 2 diabetes is 2-3x higher

12 Adverse Effects of Tobacco Use Video Clip - Smaller babies

13  Difficulty getting pregnant  Placenta separates from the womb too early, causing bleeding  Placenta covers the cervix, causing complications  Water breaks too early More studies needed: Possible adverse effect may include pregnancy occurring outside of the womb Centers for Disease Control Adverse Effects of Tobacco Use …on mom

14 Children suffer from bronchitis, pneumonia, hyperactivity, middle ear infections, upper respiratory infections and are frequently hospitalized. Adverse Effects of Tobacco Use …on family members Teens are more likely to become smokers when a parent smokes. As a result, they will suffer greater long-term health effects such as cancer, heart disease and progressive lung disease like emphysema.

15 Of particular concern are carbon monoxide, nicotine and oxidizing chemicals. Nicotine may cause constrictions in the blood vessels of the umbilical cord, thereby decreasing the amount of oxygen available to the fetus. This increases the risk of complications such as:  Miscarriage  Premature birth  Stillbirth  Spontaneous abortion Adverse Effects of Tobacco Use …on the unborn baby

16 Babies born to mothers who smoke during pregnancy have an increased risk of:  Sudden Infant Death Syndrome (SIDS)  Lower birth weight  Mental retardation  Brain dysfunction  Respiratory infections Adverse Effects of Tobacco Use …on the newborn

17  No matter what their age, most smokers want to quit and most attempt to quit every year.  Among current smokers, 70% report they want to quit completely. Facts about Quitting Smoking

18  a.Clinical Interventions b.Five A’s c.Brief Motivational Interviewing d.Pharmacotherapy e.Quit Line / Telephone Counseling Interventions

19 Recommendation: All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) Clinical Interventions

20 Recommendation : All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) Clinical Interventions

21 Recommendation: Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) Recommendation: There is a strong dose-response relation between the session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. (Strength of Evidence = A) Recommendation: Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use. (Strength of Evidence = A) Clinical Interventions

22 1. ASK the patient about smoking status at the first prenatal visit and follow-up with her at subsequent visits. a) I have NEVER smoked or have smoked < 100 cigarettes in my lifetime b) I stopped smoking BEFORE I found out I was pregnant… c) I stopped smoking AFTER I found out I was pregnant… d) I smoke some now, but I have cut down… e) I smoke regularly now, about the same as before… If a-c, Reinforce her decision to quit (or never start), congratulate her on quitting, encourage her to remain smoke free. If d-e, Document smoking status and proceed to next four A’s. Five A’s

23 2. ADVISE the patient who smokes to stop by providing advice to quit with information about the risks of continued smoking to the woman, fetus, and newborn. 3. ASSESS the patient’s willingness to attempt to quit smoking at the time. Quitting advice, assessment, and motivational assistance should be offered at subsequent prenatal care visits. Five A’s

24 4. ASSIST the patient who is interested in quitting by providing pregnancy-specific, self-help smoking cessation materials. Support the importance of having smoke free space at home and seeking out a “quitting buddy,” such as a former smoker or nonsmoker. Encourage the patient to talk about the process of quitting. Offer a direct referral to the smoker’s quit line (1-800-QUIT NOW) to provide ongoing counseling and support. Five A’s

25 5. ARRANGE follow-up visits to track the progress of the patient’s attempt to quit smoking. For current and former smokers, smoking status should be monitored and recorded throughout pregnancy, providing opportunities to congratulate and support success, reinforce steps taken towards quitting and advise those still considering a cessation attempt. Modified from Treating Tobacco Use And Dependence: 2008 update. Clinical Practice Guideline. Five A’s

26 Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future. (Strength of Evidence = B) Motivational interviewing is a technique whereby clinicians focus on the patient’s desire to quit smoking, by developing an awareness of the discordance between knowledge and behavior, and then supporting patient’s self-efficacy in achieving that desire. There are 4 principles of motivational interviewing:  Express empathy,  Develop discrepancy,  Roll with resistance, and  Support self-efficacy. Brief Motivational Interviewing

27 Nicotine Replacement Product s  Patch  Gum  Inhaler  Nasal Spray  Lozenge Pharmaceuticals  Bupropion (Zyban) Pharmacotherapy

28 “The use of nicotine replacement products or other pharmaceuticals for smoking cessation aids during pregnancy and lactation have not been sufficiently evaluated to determine their efficacy or safety.” U.S. Preventive Services Task Force, 2009 Pharmacotherapy

29 “Pregnant smokers should be encouraged to attempt cessation using educational and behavioral interventions before using pharmacological approaches. Treatment with nicotine replacement therapy during pregnancy requires that the mother be well informed about the potential risks vs. benefits.” Benowitz, Dempsey Nicotine & Tobacco Research, February 2003 Pharmacotherapy

30 “The use of nicotine replacement therapy should be undertaken with close supervision and after careful consideration and discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy.” The American College of Obstetricians and Gynecologists, 2010 Pharmacotherapy

31 Recommendation: Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. (Strength of Evidence = A) Quit lines offer information, direct support, and ongoing counseling, and have been very successful in helping pregnant smokers quit and remain smoke free. 1-800-QUIT NOW Quit Line / Telephone Counseling

32 Best Practice

33 Tips for Quitting eature=related

34 If you smoke when you:Try doing this: Drink coffeeHave hot chocolate or herbal tea Finish a mealGet right up, take a walk, or go into another room Watch TV Do something else with your hands (start a craft) and mouth (chew gum, eat a hard candy) Need to relaxTake a nonsmoking break or walk, or take a break take a bubble bath, call a friend, do your nails, ask a friend to babysit for 30 minutes, even if you stay home Tips for Quitting

35 Your hands:Your mouth: Knit or sewChew gum Play with a rubber bandEat some fresh fruit Hold a pen or pencilUse a straw or toothpick Draw or doodleSuck on hard candy Squeeze a soft rubber ballTry a cinnamon stick Work on a craft projectSip water or juice Decorate your baby’s roomHave a frozen fruit bar Massage your fingers or handsHave some popcorn It also helps to keep your hands and mouth busy.

36 Resources

37 Great tools to help people quit Online Quit Plan Resources

38 Resources

39 or Resources

40 Information for Smokers and Their Families 1-800-QUIT-NOW 1-800-QUIT-NOW -- (1-800-784-8669); TTY 1-800-332-8615. Provides support in quitting, including free quit coaching, a free quit plan, free educational materials, and referrals to local resources. Smokefree Women Smokefree Women -- Provides information and resources on quitting smoking targeted at pregnant and non-pregnant women. -- Provides general resources for smokers to quit Become an EX: For pregnant and postpartum smokersBecome an EX: For pregnant and postpartum smokers -- A quit smoking program developed by the American Legacy Foundation. Stay Away from TobaccoStay Away from Tobacco -- Smoking cessation resources for patients and providers. The March of DimesThe March of Dimes -- Quitting tips for pregnant smokers. Smoke-free homes and cars programSmoke-free homes and cars program -- Provides materials and resources for protecting children from secondhand smoke developed by the Environmental Protection Agency.. Resources

41 Information for Health Care Professionals American College of Obstetricians and Gynecologists: Smoking CessationAmerican College of Obstetricians and Gynecologists: Smoking Cessation -- Smoking cessation resources for patients and providers Centers for Disease Control and Prevention, Division of Reproductive Health Centers for Disease Control and Prevention, Division of Reproductive Health -- Highlight of data on tobacco use during pregnancy and resources. Office of the Surgeon General: Tobacco Cessation GuidelineOffice of the Surgeon General: Tobacco Cessation Guideline Clinical Practice Guidelines, Treating Tobacco Use and Dependence, is available here. The guideline was designed to assist clinicians; smoking cessation specialists; and health care administrators, insurers, and purchasers in identifying and assessing tobacco users and in delivering effective tobacco dependence interventions. This site also has clinician resources such as a Quick Reference Guide, tear sheets for primary and prenatal care providers, and consumer materials. Quick Reference Guide for Clinicians. Treating Tobacco Use and Dependence. (PDF) --This reference guide contains strategies and recommendations from the Public Health Service-sponsored Clinical Practice Guideline, Treating Tobacco Use and Dependence. (requires Adobe Reader)

42 Information for Health Care Professionals Smoke-Free FamiliesSmoke-Free Families -- Resources to help counselors of pregnant women who smoke, includes clinician resources, technical assistance tools, and patient materials. The Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) ProgramThe Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program -- An evidence-based program that can be implemented in offices to help pregnant women quit smoking. -- Presents evidence-based information about the treatment of tobacco dependence.

43 Information for Health Care Professionals American Academy of Pediatrics (AAP) American Academy of Pediatrics (AAP) -- Provides tools and resources to help clinicians and communities, and supports research and policy development to create a healthy environment for children, adolescents, and families. Also includes the AAP Policy Statement of tobacco use as a pediatric disease.AAP Policy Statement How Tobacco Smoke Causes Disease: What It Means to YouHow Tobacco Smoke Causes Disease: What It Means to You -- An easy- to-read booklet explaining new scientific findings about how deadly cigarettes are and how quickly they can damage your body. Infant Risk Center Infant Risk Center -- Provides up-to-date evidence-based information on the use of medications during pregnancy and breastfeeding.

44  Question and document tobacco use at every visit.  Understand the challenge to quit and expect relapse.  Identify readiness to quit to best tailor approach to patient.  Treatment is effective and multiple options allow for individualized interventions. Key Messages for Promoting Smoking Cessation

45 Jolie Person Maternal and Child Health Program Texas Department of State Health Services Health Service Region 1 - Canyon, Texas 806-655-7151 Thank you!

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