Lane County Public Health A Tobacco Cessation and Relapse Prevention Program Designed for use in a WIC Clinic Jennifer Jordan, MPH Lane County Public Health Eugene, OR

Background In Lane County Oregon, smoking rates during pregnancy have risen significantly since 2001 and are now higher than the state average (15.2% vs. 12.6%). Smoking during pregnancy is the single most preventable cause of illness and death among mothers and infants.

Targeting Women…again 1940’s – 1950’s 1970’s – 1980’s 2007 Women have been extensively targeted in tobacco marketing dominated by themes of an association between social desirability, independence, weight control and smoking messages conveyed through advertisements featuring slim, attractive, and athletic models. Teenage girls often start to smoke to avoid weight gain and to identify themselves as independent and glamorous, which reflect images projected by tobacco ads. Social images can convince teens that being slightly overweight is worse than smoking. Cigarette advertising portrays cigarettes as causing slimness and implies that cigarette smoking suppresses appetite. While RJR claims that it is marketing only to women, its advertising and promotions tell a different story. Slick ads for Camel No. 9 have run in magazines popular with girls, including Vogue, Glamour, Cosmopolitan, Marie Claire and InStyle. Promotional giveaways include berry lip balm, cell phone jewelry, cute little purses and wristbands, all in hot pink.

Background Low-income women and those with less than 12 years of education are more likely to smoke during pregnancy and have less access to cessation support. Pregnancy is a unique “window of opportunity” to influence behavior change. Tobacco use and its related health consequences are not distributed equally throughout society. Targeting smoking interventions for low-income pregnant and postpartum women has the potential to realize long-term public health benefits.

Background Approximately 20-30% of women who smoke before pregnancy quit when they learn they are pregnant and an additional 20-30% quit after entering prenatal care. Unfortunately, at least half of these women resume smoking within the first 6 months postpartum and 80% relapse within the first year postpartum. The Women, Infants, and Children (WIC) program serves over 42% of all pregnant women in Lane County providing an ideal opportunity to reach this critical target population.

Purpose Quitting for Keeps aims to increase access to tobacco relapse prevention and cessation services among low-income pregnant and postpartum women utilizing WIC services. This community-based participatory research project collaborated with WIC staff and clients to modify the traditional 5A’s cessation intervention to a briefer 3A’s model that was tailored for the WIC setting and more easily incorporated into a client’s visit.

Materials & Methods Lane County Public Health partnered with the Oregon Research Institute (ORI) to tailor ORI’s 3A’s (Ask, Advise, & Arrange) brief cessation intervention model for the WIC setting (see diagram).

Flow Chart

QFK Logic Model This logic model framework represents how planned program inputs and activities linked to outcomes.

Materials & Methods Three focus groups were conducted with WIC clients and staff to identify opportunities and barriers to providing brief tobacco cessation and relapse prevention interventions. The input was used to adapt resources and tools for staff and clients, including a staff training, fact sheets on tobacco use and pregnancy, and a Quitting for Keeps resource guide.

Materials & Methods In a Quitting for Keeps training on the 3A’s brief intervention technique, we included strategies for dealing with defensive clients, motivating clients who have previously been unsuccessful, using nonjudgmental approaches, communicating the potential health effects of tobacco, and referring clients to community resources. (e.g. the Quit Line)

Materials & Methods In November 2007, the counselors began incorporating the intervention in their client visits. Additionally, a “Quit Information” workshop was available every three months that met clients’ class requirements to receive their WIC vouchers.

Materials & Methods Clients responded to follow-up phone surveys at 6 weeks, 6 months, and 12 months post-intervention. Reports summarizing the number of interventions completed, the number of quit dates set, and client satisfaction were shared and discussed with WIC counselors at their monthly staff meetings.

Results 3A’s Staff Training Results (pre/post) Knowledge scores increased from average of 52% to 83% (p < .05); confidence scores also increased, but not significantly (n=11) Intervention Data: 327 women received the 3A’s 62% pregnant; 38% postpartum 84% were current smokers 17% (n=57) set a quit date during the intervention

Results 6 Weeks Post-Intervention Survey: 60% (n=160) response rate 65% felt staff advice was useful; 55% reported the materials were useful Of those who had not quit, 75% reported trying to quit in the last six months and 58% reported they were seriously considering quitting in the next 30 days

Results Preliminary 6 Month Post-Intervention Data: 46% response rate (n=45) 19% report cutting back and 20% report quitting and remaining quit

Status of Women Receiving Intervention (n-327)

Smoking Status at 6 weeks (n=120)

Lessons Learned Systematic cessation and relapse prevention training among WIC staff can successfully increase counseling practices. Periodic feedback on the effectiveness of smoking interventions and opportunities for input are important motivators for providers to implement cessation promotion and relapse prevention. Challenges include: making the intervention a priority; attrition on follow-up surveys; client recruitment for the cessation support class; and staff turn over.

Acknowledgements We would like to thank the Lane County WIC staff for their invaluable support of Quitting for Keeps and the great work they do every day. Thanks also to Ed Lichtenstein at ORI for his advice and feedback. Quitting for Keeps was funded by a grant from the American Legacy Foundation® and we’ve truly appreciated the technical assistance and support provided by Robin Scott and Scott Thomas. Additional thanks to Laura Hammond, Connie Sullivan and Karen Gillette for their support, assistance, and encouragement.