Smoking During Pregnancy Nicki Croel, Suad Ali, Vaughn Lovell, Tyler Baerwolf, Dan Herbert, Erin White, Nikki McDonald

Community Assessment Mecosta County Population: 43,000 Median HH income: $37,677 Persons below poverty: 23.6% Ethnicity: 93.2% non-Hispanic white Education: 88.7% high school grads, 21.6% bachelors degree

Pregnant Women 31.4% of women in Mecosta County smoked while pregnant 19.3% of women in Michigan smoked while pregnant Healthy People 2020 goal is to decrease smoking while pregnant to 1.4% as a nation. Women may be reluctant to disclose their smoking status during pregnancy, deception rates are as high as 23% among Medicaid populations and 14% among private insured women.

Healthy People 2020 - Tobacco Use and Environmental Health are both topics of Healthy People 2020 Tobacco Use $193 billion in health care costs related to tobacco use each year. “Tobacco use is the single most preventable cause of death and disease in the United States.”

Analysis of Findings Strengths Rate of low birth weight is 6.2% vs. MI at 8.4% Teen pregnancy rate at 28.7% vs. MI at 48.3% High school grad rate is at parity with MI Weakness Poverty level high at 23.6% vs. MI at 15.7% Medicaid pays for 54.9% of births in Mecosta County Food desert Limited access to healthcare The CDC defines Low birth rate as: Percentage of live born infants with birth weight less than 2 500g or 5.5 lbs. Also according to the CDC: Food deserts are defined  as parts of the country without fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas. This is largely due to a lack of grocery stores, farmers’ markets, and healthy food providers

Resources Available Michigan Tobacco Quit Line Michigan Department of Community Health- Smoke Free for Baby and Me Options Pregnancy Resource Center Mid Michigan Community Action Agency District Health Department #10 Maternal Infant Health Program – Smoking Cessation Supplemental Nutrition Program for Women, Infants, and Children (WIC) Spectrum Health – Big Rapids Hospital & affiliated practices In 2010, Michigan's Medicaid program provided incomplete coverage through Medicaid for tobacco-dependence treatment. Michigan provided full coverage for some nicotine replacement therapies, partial coverage for varenicline, partial coverage for bupropion, and full coverage for individual counseling Options Pregnancy Resource Center is a faith based organization providing pregnancy and post partum support. Mid Michigan Community Action Agency has Early Head Start, which is a free program offered to pregnant women, infants, toddlers and their families.

Nursing Diagnosis Risk of: Poor infant outcomes Among: Pregnant women in Mecosta County Related to: Smoking while pregnant As demonstrated by: elevated infant mortality rates in Mecosta County linked to maternal smoking while pregnant. The infant mortality rate in the State of Michigan is 7.3/1000 live births In Mecosta county the rate is 9.1/1000 live births Other health risks related to smoking while pregnant include spontaneous abortions, stillbirths, fetal growth restriction, SIDS, preterm birth, neuro-developmental disorders, and cancers.

Problem Statement Mecosta County has a higher than average maternal smoking while pregnant rate at 31.4% vs. the State of Michigan at 19.3% The rate could be due to a variety of reasons, but some of the major reasons are lack of prenatal care in this rural community and high poverty rates.

Goals & SMART Objectives: 2-3yrs- Implement a prevention and smoking cessation program within Mecosta county aimed at women who smoke while pregnant. 5yrs- 5% decrease of smoking while pregnant 10yrs- At parity with the state of Michigan with smoking while pregnant SMART- The rate of smoking while pregnant will decrease by 5% after implementation of smoking cessation programs for pregnant women in Mecosta county in 5yrs.

Evidence Based Secondary Prevention SCRIPT Method Evidence based program cited by the Agency for Healthcare Research and Quality’s Smoking Cessation Clinical Practice Guidelines 4 Components Pregnant Woman’s Guide to Quit Smoking Commit to quit smoking during and after pregnancy Comprehensive Counseling Counseling and encouragement to establish a non-smoking home Smoking Cessation and Reduction in Pregnancy Treatment Guide: 40 page tailored guide that outlines a self evaluation process to build a women’s smoking cessation success over a 7 day period, written at a 5-6th grade reading level Commit: 15 minute motivational DVD that presents testimonials of pregnant smokers who quit Counseling: Focused on helping pregnant smokers quit or significantly reduce smoking during pregnancy Encouragement: Follow-up components are a part of the SCRIPT program to help prevent smoking relapse Cessation rates were found to be around 10% in Medicaid receiving women, which is significantly lower than other intervention programs we found

Evidence Based Secondary Prevention Continued Telephone Smoking Cessation Quit-line American Cancer Society- analysis of telephone quit-line data Three Options- Selected by pregnant woman Self-Help Materials only Self-Help Materials with Phone Counseling Phone Counseling only Phone Counseling: 8 Telephone counseling sessions; Compared to self-help materials or minimal advice, telephone counseling increases quit rates by about 60% among smokers. There was limited detailed information about this type of intervention, and we found another program with better cessation rates.

Evidence Based Secondary Prevention Continued The Five A’s Counseling program Recommended by the National Cancer Institute, American College of Obstetricians and Gynecologists, and U.S. Public Health Services Effective in a variety of settings We decided to implement the 5 A’s Smoking Cessation Program 5 A’s: Low Impact, Short counseling sessions, about 5-15 minutes by a trained smoking cessation provider and self-help materials specific to pregnant women Effective in offices, clinics, and the classroom settings, which is a cost effective method to provide services

Geopolitical Community Research Study looked at 16 smoking cessation programs already in place The State of Tennessee implemented the program statewide in their WIC clinics, permanently Wide variety of participants, locations, demographic enrolled Our population Studies looked at participants in WIC clinics, Private and University Clinics, Public Clinics, and Health Departments across the nation This program has been studied and implemented in numerous settings, population bases, and demographics, all with success. The sample size is so large and varied across programs, we can expect this intervention would work for Mecosta County. We are planning to work with a similar group of providers, so we can expect similar outcomes. Since this is a rural county and transportation may be limited, we may need to accommodate increased travel costs or mailing costs in our budget.

Stakeholders & Partners WIC Maternal Infant Health Program (MIHP) Spectrum Hospital Big Rapids Local Ob/Gyn and Primary Care offices Great Start Collaborative Mid-Michigan Community Action Agency Options Pregnancy Resource Center Our first step would be to start a coalition in Mecosta with interested stakeholders. Support from representatives from the respective agencies would be needed to build and implement this program. We would also need their support to sustain it once grant funding has been depleted. Once outcomes of the program have shown a reduction in rates we could partner with Michigan Department of Community Health to integrate this program long term, like the Tennessee Department of Health did in their WIC clinics. We would need agreements of non-disclosure from these agencies. We could work with WIC and MIHP to get the smoking cessation program in their client agreement, so there are no other forms for their clients to sign. We would partner with other agencies to establish the best method to get referrals from their clients or patients.

Plan Overview Grant Funding Develop materials Training Launch Five A’s Counseling Program Grants from the W.K. Kellogg Foundation and the Mecosta County Community Foundation totaling: $32,500 Materials: Brochures, posters, flyers, webpages, video Training for counselors

Year 1 Estimated Expense Budget Income Kellog Foundation $30,000 Mecosta $2,500 Subtotal $32,500 Expenses Marketing - Brochures, Posters, flyers etc. $7,500 (10K pieces @avg. $.075/ea.) Video (script/production) Graphic/Web Design (internal FTE, burdoned) $1,500 (60hrs @$25/hr) 2 Counselors (internal FTE, burdoned) $15,000 2hrs X 5 days X 50 weeks = 500 hrs. 500 hrs X $30/hr = $15,000 $31,500 Total $1,000

Five A’s Counseling Steps Ask Determine a women’s smoking status Advise Urge smokers to quit using a clear, strong, and personalized messages Assess Willingness to quit smoking in the next 30 days If unwilling, reinforce at subsequent visits These steps for smoking cessation during pregnancy have been shown to bring a 70% success rate. Ask: Implement an office system that ensures that, for every patient at every visit, tobacco use status is queried and documented. Patients who quit since they found out they were pregnant need recognition and encouragement to prevent relapse Advise: These messages should be about the impact of smoking and quitting on the mother and fetus Assess: Ask every tobacco user if s/he is willing to make a quit attempt at this time: For example you can say “Quitting smoking is one of the most important things you can do for your health and your baby’s health. If we give you some help, are you willing to try?” · If willing to quit, provide assistance & refer to intensive treatment as needed · If unwilling to quit, provide motivational intervention.

Steps Continued Assist Arrange Provide materials and social support Continue follow up and reinforcement Assist: Help the patient with a quit plan: · Set quit date within 2 weeks · Tell family and friends · Help the patient anticipate challenges · Remove tobacco products from environment Provide practical counseling focusing on problem-solving and skills training: · Advise total abstinence · Review past quit experience · Identify triggers or challenges and brainstorm strategies before they happen · Avoid alcohol · Develop a plan for dealing with smokers in the house Provide a supportive clinical environment. Help patient develop social support in his/her environment. Provide supplementary materials. Arrange follow up: Schedule follow-up contact, either in person or via telephone, especially during first week then within first month after quit date. Congratulate success, encourage maintenance to stay smoke free!! If tobacco use has occurred: · Ask for recommitment to total abstinence · Review circumstances that caused lapse · Use lapse as a learning experience · Consider referral to more intensive treatment

Local Resources Work space Needed Community Interests Trained counselors Promotional & Educational Materials Community Interests WIC & MIHP Partnering with the Health Department would potentially give us access to a workspace, phone, computer, and Internet We will propose that we train a Public Health Nurse at the Health Department to provide smoking cessation counseling, mailings, and keep track of progress. The study suggests having a Bachelor’s educated person provide counseling. Out of the Coalition we will form a workgroup to develop promotional and educational materials. The WIC Director is aware of the high number of pregnant smokers in the district. They would be willing to partner with the coalition for this intervention. District 10’s MIHP’s smoking cessation program centers around care providers being willing to prescribe Nicotine Replacement Therapy (NRT). Care providers in Mecosta county are reluctant to prescribe NRT to pregnant women, so their smoking cessation program is not being widely utilized. They would be willing to partner for alternative methods.

Evaluation Short-term Long-term Number of referrals from stakeholders Number of participants enrolled in counseling Progress of participants each quarter Long-term Compare data from each year to the baseline rates in 2013 5% decrease in 5 years On par with the State of Michigan in 10 years

Conclusion Mecosta county has a high rate of smoking while pregnant due to many factors Lack of prenatal care High poverty levels Lack of an effective smoking cessation program available to them By implementing the 5 A’s smoking cessation program and utilizing the resources already available we will be able to reduce this number significantly Within 5 years there should be a rate reduction of 5% among pregnant smokers and by 10 years Mecosta County should be on par with the state of Michigan’s rate of smoking while pregnant

References Centers for Disease Control and Prevention. (2012, September 24). A look inside food deserts. In CDC Features. Retrieved October 2, 2013, from http://www.cdc.gov/features/fooddeserts/ Centers for Disease Control and Prevention. (2009, October 29). PedNSS health indicators. In Pediatric and Pregnancy Nutrition Surveillance System. Retrieved October 2, 2013, from http://www.cdc.gov/pednss/what_is/pednss_health_indicators.htm District Health Department 10, (2012). Health profile chartbook 2012: Mecosta county. Retrieved from website: http://dhd10.org/images/Mecosta_Chartbook_Dec_14_2011-1.pdf East Tennessee State University. (n.d.). 5 A's guide. In Tennessee Intervention for Pregnant Smokers. Retrieved October 2, 2013, from https://www.etsu.edu/tips/participating/intervention.aspx Melvin, C., Dolan-Mullen, P., Windsor, R., Whiteside, H. P., & Goldenberg, R. (2000). Recommended cessation counselling for pregnant women who smoke: A review of the evidence. Tobacco Control, 9, Retrieved from www.tobaccocontrol

References Continued Muecke, M. (1984). Community health diagnosis in nursing. Public Health Nursing, 1(1), 23-35. Retrieved from https://fsulearn.ferris.edu/bbcswebdav/pid-349635-dt-content-rid-1923521_1/xid-1923521_1 National Center on Addiction and Substance Abuse. No place to hide: Substance abuse in mid-size cities and rural America . Commissioned by the United States Conference of Mayors. Funded by the Drug Enforcement Administration with support from the National Institute on Drug Abuse, 2000 Society for Public Health Education. (n.d.). The smoking cessation and reduction in pregnancy treatment (SCRIPT) program. InSOPHE. Retrieved October 2, 2013, from http://www.sophe.org/SCRIPT.cfm Snattingius, S. (2004). The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes. Nicotine & Tobacco Research, 6(2), S125-S140. doi: 10.1080114622200410001669187 U.S. Department of Health and Human Services. (2013, August 28). Family planning. In Healthypeople.gov. Retrieved October 2, 2013, from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=13