1. Using the 5A’s SIDS Mid-Atlantic presents

2. Presented by Health Care Education & Training, Inc. 2 Created March 2002 SIDS Mid-Atlantic 2700 S. Quincy St. Suite 220 Arlington VA 22206 703-933-9100 www.sidsma.org sidsma27@aol.com Betty Connal, RN, MS, Director

3. Presented by Health Care Education & Training, Inc. 3 Created March 2002 Objectives To establish evidence-based, best practice prenatal smoking cessation interventions as a routine part of prenatal care by training health care providers in the Five A’s Method of Smoking Cessation To assure that all pregnant women in Virginia are asked about their use of tobacco and that all pregnant smoking women in Virginia receive evidence-based treatments in smoking cessation

4. Presented by Health Care Education & Training, Inc. 4 Created March 2002 Program Objectives Describe the 5A prenatal smoking cessation method Incorporate the 5A prenatal smoking cessation method into the standard protocol Identify readily available smoking cessation resources

5. Presented by Health Care Education & Training, Inc. 5 Created March 2002 Agenda Introduction Ask Advise/Assess Assist/Arrange for follow-up Implementation issues and role play Resource identification Wrap-up

6. Presented by Health Care Education & Training, Inc. 6 Created March 2002 Risks of Smoking in Pregnancy Smoking remains the single most important preventable cause of poor birth outcome 20% low birth weight deliveries 8% pre-term births 5% perinatal deaths

7. Presented by Health Care Education & Training, Inc. 7 Created March 2002 Risks of Smoking Placenta previa Miscarriage Ectopic pregnancy Preterm Premature Rupture Of Membranes Abruptio placenta

8. Presented by Health Care Education & Training, Inc. 8 Created March 2002 Risks of Smoking Low birth weight Small for gestational age Preterm delivery 3 to 4 times greater risk of Sudden Infant Death Syndrome (SIDS) Stillbirths

9. Presented by Health Care Education & Training, Inc. 9 Created March 2002 Smoking effects on the baby Otitis media (ear infections) Asthma Bronchitis and pneumonia Wheezing and lower respiratory illness

10. Presented by Health Care Education & Training, Inc. 10 Created March 2002 Who is at Risk for Premature Birth? The best predictor of having a preterm birth is a history of preterm labor/delivery or prior low birthweight

11. Presented by Health Care Education & Training, Inc. 11 Created March 2002 Risk factors for premature birth  multifetal pregnancy—twins, triplets and more  maternal age ( 35 years)  black race  low SES  unmarried  previous fetal or neonatal death  3+ spontaneous terminations  uterine abnormalities  incompetent cervix  genetic predisposition

12. Presented by Health Care Education & Training, Inc. 12 Created March 2002 Risk for premature birth  low pre-pregnant weight  obesity  infections  bleeding  anemia  major stress  lack of social supports  tobacco use  illicit drug use  alcohol abuse  folic acid deficiency

13. Presented by Health Care Education & Training, Inc. 13 Created March 2002 Signs of Premature Labor Contractions every 10 minutes or more Changes in vaginal discharge (leaking fluid or blood from vagina) Pelvic pressure—baby pushing down Low dull backache Cramps that feel like a period Abdominal cramps with or without diarrhea

14. Presented by Health Care Education & Training, Inc. 14 Created March 2002 Why use the Five A’s? About 35% of women will quit smoking during pregnancy, benefiting themselves, their next pregnancy, their children and their families

15. Presented by Health Care Education & Training, Inc. 15 Created March 2002 Cost of Complicated Births Smokers average cost of birth $11,000 Non smokers average cost of birth $6500

16. Presented by Health Care Education & Training, Inc. 16 Created March 2002 Cost Effectiveness of Smoking Cessation Intervention Cost per life year saved, in thousands of dollars Smoking Cessation Intervention $2500 Mammography $50,000 Treatment of high cholesterol $100,000

17. Presented by Health Care Education & Training, Inc. 17 Created March 2002 Timing of Health Benefits 1990 Surgeon General’s Report 20 minutes Blood pressure, heart rate return to normal 8 hours O 2 level returns to normal; nicotine and CO levels reduced by half 24 hours CO is eliminated from body; lungs begin to eliminate mucus, debris 48 hours Nicotine eliminated from body; taste and smell improve 72 hours Breathing is easier; bronchial tubes relax; energy levels increase 2 to 12 weeks Circulation improves 3 to 9 months Lung function increases by up to 10%; coughing, wheezing, breathing problems reduced 1 year Heart attack risk halved 10 years Lung cancer risk halved 15 years Heart attack risk same as for someone who never smoked

18. Presented by Health Care Education & Training, Inc. 18 Created March 2002 Intervention Works Smoking cessation intervention by clinicians improves quit rates Brief counseling (5 to 15 minutes total) is all that is needed to help many pregnant smokers quit A woman is more likely to quit smoking during pregnancy than at any other time in her life

19. Presented by Health Care Education & Training, Inc. 19 Created March 2002 The 5A approach Ask about patient’s habits. Advise of consequence of smoking. Assess willingness to quit. Assist with cessation plan development. Arrange for follow-up

20. Presented by Health Care Education & Training, Inc. 20 Created March 2002 Research Conclusions 1. Brief cessation counseling session can improve cessation rates as compared to simple advice to quit 2. More intensive counseling has not been documented to increase cessation rates 3. Benefits of brief counseling effective in light to moderate smokers (less than a pack per day)

21. Presented by Health Care Education & Training, Inc. 21 Created March 2002 Ask A. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime. B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. Goal: Find out if patient smokes or has recently quit.

22. Presented by Health Care Education & Training, Inc. 22 Created March 2002 Ask (cont) C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. D. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant. E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.

23. Presented by Health Care Education & Training, Inc. 23 Created March 2002 Advise Goal is to either: 1) present compelling evidence about the importance of quitting 2) encourage recent quitters to continue abstinence. Message must be strong, clear, and relevant to specific patient’s concerns.

24. Presented by Health Care Education & Training, Inc. 24 Created March 2002 Advise Examples Appropriate: “Ms. Smith, it is important for you to quit smoking. As your Resource Mother, I need you to know that quitting smoking increases your chances of having a healthy baby. Your health will also improve...” Inappropriate: “Ms. Smith, you need to quit smoking.”

25. Presented by Health Care Education & Training, Inc. 25 Created March 2002 Create an Advise Statement Maria is 19-year old woman with two children. She has smoked since she was 16 years old. She has indicated that she smoked with her first two children and “they are fine.”

26. Presented by Health Care Education & Training, Inc. 26 Created March 2002 Advise example for recent non- smoker “Ms. Smith, I want to congratulate you on making such an important decision for your baby’s health. As your nurse, I need you to know that quitting smoking has greatly increased your chances of having a healthy baby. Your health will also improve….”

27. Presented by Health Care Education & Training, Inc. 27 Created March 2002 Three patient types Current smoker who wants to quit. Recent non-smoker Current smoker who does not want to quit. Target of Assess step

28. Presented by Health Care Education & Training, Inc. 28 Created March 2002 Assess Decision Flow Yes Does patient currently smoke? Patient willing to quit? Provide appropriate cessation techniques (Step 4 of 5A approach) Yes No Provide motivational materials and counseling

29. Presented by Health Care Education & Training, Inc. 29 Created March 2002 Assess Decision Flow (cont) Yes Does patient currently smoke? Has patient smoked in the past? Assist with cessation maintenance (Step 4 of 5A approach) No

30. Presented by Health Care Education & Training, Inc. 30 Created March 2002 Dealing with the resistant patient 1. Find out why patient doesn’t want to quit. 2. Emphasize risks of smoking. 3. Point out the rewards of quitting. 4. Discuss roadblocks and ways to overcome them.

31. Presented by Health Care Education & Training, Inc. 31 Created March 2002 Patients Who Decline to Quit: Using the 5 R’s RelevanceRisksRewardsRoadblocksRepetition

32. Presented by Health Care Education & Training, Inc. 32 Created March 2002 Assist Why people smoke: Addicted to nicotine Enjoyment Common triggers: After eating Social situations

33. Presented by Health Care Education & Training, Inc. 33 Created March 2002 Assist (cont) Roadblocks: Friends all smoke Doesn’t really want to quit but feels should quit Rewards: Clothes and breath will smell better Cough will go away

34. Presented by Health Care Education & Training, Inc. 34 Created March 2002 Assist: Coping Strategies Why people smoke: Addicted to nicotine/Drink lots of water Enjoyment/Do something else enjoyable Common triggers: After eating/Eat breath mint Social situations/Avoid situations where there’s smoke

35. Presented by Health Care Education & Training, Inc. 35 Created March 2002 Assist: Coping Strategies (cont) Roadblocks: Friends all smoke/Talk on phone instead of in person Doesn’t really want to quit but feels should quit/Identify personal reasons to quit Rewards: Clothes and breath will smell better/Wash all clothing Cough will go away/Track number of coughing bouts per day

36. Presented by Health Care Education & Training, Inc. 36 Created March 2002 Smoking Cessation Plan Step 1. Identify why, common triggers, and major roadblocks. Step 2. Identify rewards. Step 3. Establish a quit date. Step 4. Identify cessation method and coping strategies. Step 5. Provide resources.

37. Presented by Health Care Education & Training, Inc. 37 Created March 2002 Arrange for follow-up For patient who has remained smoke-free, offer congratulations. For patient who has relapsed, return to Assist step in 5A approach.

38. Presented by Health Care Education & Training, Inc. 38 Created March 2002 Relapse Questions What was the trigger? When did the relapse occur? What was going on in your life at the time of relapse? Did you have a support person there? What techniques did you try to help you work through the craving? Would you like to set another quit date?

39. Presented by Health Care Education & Training, Inc. 39 Created March 2002 Reimbursement ICD-9-CM code 305.1 (tobacco use disorder, tobacco dependence) AND CPT code 99401 (15-minute physician-provided counseling)  with modifier 25 as part of regular prenatal visit OR CPT code 99211 (nurse counseling)

40. Presented by Health Care Education & Training, Inc. 40 Created March 2002 Resources SIDS Mid-Atlanticwww.sidsma.orgwww.sidsma.org Go to ‘Professionals’ ‘Stop Smoking Stop SIDS Program’ Links to state and national info and resources March of Dimes www.marchofdimes.com www.marchofdimes.com

41. Presented by Health Care Education & Training, Inc. 41 Created March 2002 Great Start 1-866-66Start Interactive Quitline for Pregnant Smokers

42. Presented by Health Care Education & Training, Inc. 42 Created March 2002 Resources Smoke Free Families www.smokefreefamilies.org www.smokefreefamilies.org National Partnership to Help Pregnant Smokers Quit www.helppregnantsmokersquit.org www.helppregnantsmokersquit.org

43. Presented by Health Care Education & Training, Inc. 43 Created March 2002 Virginia Quit Line 1-800-QUIT NOW