1. STARSS Start Thinking About Reducing Secondhand Smoke: A harm reduction support strategy for low- income mothers who smoke Developed by AWARE: Action on Women’s Addictions – Research and Education info@aware.on.cainfo@aware.on.ca www.aware.on.cawww.aware.on.ca

2. Project Background Pilot project in Ontario with CAPC(2002- 2005) funded by Health Canada FTCS Ontario Region and Office of Mass Media Phase 1 of the National Rollout of STARSS (2006-2007) funded by Health Canada FTCS National Office Phase 2 of the National Rollout of STARSS (2009-2010) funded by the CAPC/CPNP National Projects Fund, Public Health Agency of Canada STARSS for CHC/PHU (2011-2013) funded by the Ministry of Health Promotion & Sport

3. Why STARSS – research perspective Rates of smoking still higher in marginalized groups May be especially high among women/moms in CAPC/CPNP projects Research suggests low-income mothers “need an approach focussed on motivation and decision-making, not advice about quitting smoking”

4. Why STARSS – moms’ perspective Conscious of the harms of SHS to their kids Express guilt & remorse for SHS exposure Standard strategies not realistic to their lives, especially if single parents Fear reprisal from child protection services if they smoke Want realistic & attainable strategies

5. Women’s Voices “ I can’t leave my kids alone to go outside to smoke. The logistics are just too difficult. Either the kids tear the house apart. Or if they’re asleep and wake up, they scream because they’re scared.” “I smoke but I try as hard as I can not to smoke around my kids. But then their grandparents come over and they smoke. I can’t ask them not to smoke because I do. So then we’re all smoking. We try to vent the smoke to the outside.”

6. Why Women Smoke Acts as an appetite suppressant Gives a sense of control over a life that may feel is out of control A chance to take a break and breathe A reward – the one thing they do for themselves A way to cope with difficult emotions/stress A friend To feel part of a social group Partners, friends, family who smoke

7. Why It’s Hard to Quit Addicted Very difficult life circumstances Poverty Abuse (current or history of trauma) Partners, friends, family who smoke Surveillance (from ex-partners, child protection services, community)

8. Who Benefits from STARSS STARSS was designed to meet the needs of women who: live on a low-income are single parents (which may mean they have a part time partner) & have children under age 6 receive support from service providers who don’t necessarily have experience with tobacco strategies are not ready to quit smoking (i.e., precontemplators and contemplators)

9. Not Ready to Quit Abstinence is healthiest for everyone – no known safe level of smoking BUT: abstinence not always possible Focus on positives of reducing smoking: – Smaller, more manageable steps – Accomplishments can increase confidence – Can eventually move to quitting – Keeps participant engaged

10. Challenges for Program Staff Fear of turning women away from basic services No time to provide interventions Lack of skills and knowledge about smoking Competing priorities

11. Challenges for Program Staff Many staff may be smokers themselves Often, staff have had negative experiences providing smoking cessation programs Dislike of traditional non-smoking messages

12. Existing Messages What are some of the negative messages in campaigns/programs on smoking cessation? Advice based All or nothing Focus on quitting Punitive Guilt based Judgemental Non-supportive

13. Existing Messages Think about the women we work with. How do these traditional messages impact them? Tune out Feel like a failure Feel guilty – leads to more smoking Feel defeated before even beginning Feel like a bad parent Feels unattainable Avoid/ignore the message/resources Doesn’t work

14. STARSS Message Women wanted an approach that supports the role of moms (especially if they are sole parents), acknowledges the love they have for their children, and affirms measures moms already take to protect their children in a variety of ways

15. STARSS Message The message emphasizes the many things moms do to protect children and includes smoking outside as one of those things “Just because I smoke doesn’t mean I don’t love my children.”

16. Philosophy Harm Reduction  not smoking cessation  “success” is measured by small steps Strengths based  acknowledges the love moms have for their children  positives are emphasized and self-efficacy is nurtured Cognitive approach  encourages moms to think through their behaviours in order to make changes  gives moms skills to help them make a quit attempt when they’re ready Goal setting strategy  builds on every change a mom makes (no matter how small) to the larger goal of smoking outside (not quitting)

17. Philosophy Empowerment  gives moms a sense of control over their smoking and their lives  setbacks are not failures but an opportunity to try a different approach Participant focused  moms guide the entire process  we meet them where they are in their process Flexible  can be used in existing programs or be a program on its own  can be used one-on-one or in a group setting  can be introduced formally or informally

18. Components The Guide to STARSS Strategies (a guidebook for service providers) The I’m A STAR! Journal (a workbook for moms) How To Be a STAR!: The STARSS Train- the-Trainer Guidebook (for trainers/service providers) Series of posters Magnets, window clings, stress “squeezies” Newsletters and other resources from the website

19. Contents The Guide to STARSS Strategies has 6 sections that include: Welcome (issues) How to use STARSS STARSS sessions (the 7 individual sessions to use with moms one-on-one) Worksheets Handouts Appendix

20. How To Use STARSS 1.Posters and Handouts Put up posters Leave out the following handouts:  What works!  Effects of Second-hand Smoke on Children  What Smoking Costs  How to Be a Star! Second-hand Smoke Protection Rotate posters and handouts Make sure there aren’t other posters/handouts that contradict the STARSS message Have snacks in the shape of stars Hang/decorate your organization with stars Have kids do a star activity Good way to first introduce topic of smoking into your organization Generates interest among participants Increases staff confidence to discuss smoking issues

21. How To Use STARSS 2. Handouts and Worksheets in Existing Groups Put out What works! Handout before a group This may start discussion or promote questions Introduce the topic starting with the positives that moms already do to protect their kids Distribute and discuss worksheets or handouts. The following are good ones to use (may only have time for one):  Worksheet 1: Short term Goal Examples  Worksheet 3: How to choose a Smoking Place  Worksheet 2: DEEDS  Worksheet 4: Positives and Negatives of Smoking  What Works! Handout Have a discussion/activity that talks about the facts and myths of second hand smoke Keep the discussion away from quitting

22. How To Use STARSS 3. STARSS Workshop or Series Once the moms in your program are familiar with the STARSS materials, you can offer to hold a specific discussion group Could be one session or 2 – 3 sessions Talk about and validate the reasons women smoke and why it is hard to quit Discuss all the ways women protect their children and introduce STARSS as one other way she can protect her child from second-hand smoke Distribute and discuss Worksheets 1 - 4

23. How To Use STARSS 4. Individual or One-to-One Sessions Each session can be delivered as part of regular contacts you already have with women There are 7 sessions:  First 2 take a little longer but the remainder take no more than 20 min each Sessions do not need to be every week Participant led – depends on the woman’s readiness to move on

24. Learnings from the Ontario Pilot Focussed on the individual, one-to-one sessions 30% had a long-term goal of quitting smoking – half achieved it at 6 months Confidence ratings were increased by 40% after participation 79% made at least one quit attempt during participation All participants reduced smoking by 50%

25. Learnings from the National Rollout Integration of STARSS strategies depended upon site capacity Some offered all of the different methods of delivery Others originally offered minimal or informal strategies only However, these sites were able to do far more than they originally thought Minimal and informal strategies were the easiest to integrate and were effective with participants

26. Learnings from the National Rollout STARSS is easy to use and integrate Implementing STARSS does not add a burden to work loads Self efficacy of staff greatly improved Make it FUN! Good buy-in from staff & participants Participants respond well There have been adaptations and ripple effects locally and regionally

27. Moms’ Stories “I was attracted to STARSS because they weren’t trying to pressure me to quit smoking or trying to make me feel guilty. I wouldn’t have gotten involved in the first place if they were trying to get me to quit.” “I’m not ready to quit smoking again. But being involved with STARSS has made a number of big changes in my life.”

28. Service Provider Stories “I learned how to stay hopeful and involved, even if the women didn’t quit smoking.” “Before STARSS, I was reluctant to talk about smoking with moms. It felt like such a huge issue and I really didn’t know what to say or do. I was reassured you didn’t have to get moms to quit smoking; it’s just as important to develop a rapport about secondhand smoke and protecting children.”

29. Points to Ponder Even minimal interventions are effective More intensive interventions are manageable and even more effective It’s all in the approach we take! “It was easy to piggyback STARSS onto our existing programs. We were able to fully integrate it into everything we do. So, instead of it being one in a long list of programs that we offer, STARSS became part of everything that we offered.”

30. Take a Walk Through... … the STARSS section of the website Go to www.aware.on.ca/starss www.aware.on.ca/starss www.aware.on.ca/starss/starss-resources www.aware.on.ca/starss/starss-newsletter www.aware.on.ca/starss/starss-mom-newsletter www.aware.on.ca/starss/starss-showcase www.aware.on.ca/starss/starss-action www.aware.on.ca/starss/starss-presents www.aware.on.ca/starss/starss-training