1. Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data from the First Two Years of TIPS Beth A. Bailey, PhD Associate Professor of Family Medicine Director, Tennessee Intervention for Pregnant Smokers East Tennessee State University

2. Overview of Today’s Session Describe the TIPS program and its effectiveness in the first two years Specifically, describe the changes in pregnancy smoking behavior of participating women Also, examine characteristics of the program that predict smoking reduction, cessation, and quit attempts Finally, examine the association between pregnancy smoking status, change in status, and birth outcomes 2

3. Background Rates of pregnancy smoking have been declining in the United States – decrease of 42% in the last 15 years Nationally, 11% of pregnant women smoke during pregnancy Rates are significantly higher in many regions of the country and within certain population groups 3

4. Background The statewide rate of pregnancy smoking in Tennessee is 17%, the third highest rate in the nation In Northeast Tennessee, rates of pregnancy smoking range from 25-43%* - more than double the state average and as much as quadruple that of the national average Rates are higher among Caucasian women, those receiving government assistance, and those living in the most rural areas * Data source–delivery chart reviews in Washington, Carter, & Sullivan Co hospitals 4

5. Background 5 Hospital20062007Change JCMC 31.4%33.0%↑1.6% JCSH 14.5%17.1%↑2.6% Indian Path * 29.7%37.5%↑7.8% Sycamore Shoals 42.5%37.6%↓4.9% Local Pregnancy Smoking Rates by Delivery Hospital and Year

6. Background 6 GestationInfancyChildhoodAdolescence E FFECTS ARE SEEN DURING : SMOKING NEGATIVELY AFFECTS: Gestational Development Infant Morbidity and Mortality Physical Health Psychological Health Growth Behavior Emotional Regulation Attention

7. Background Ectopic pregnancy Intrauterine growth restriction Placenta previa Placental abruption PROM Miscarriage Preterm delivery 7

8. Background National studies have reported links between pregnancy smoking and poor birth outcomes Our local findings indicate*: –Compared with those born to non- smokers, newborns of smokers were nearly 350gm lighter, 1 inch shorter, and were born almost 1 week earlier –Babies born to smokers were nearly twice as likely to be classified as low birth weight, to be born preterm, and to be admitted to the NICU 8 * Bailey BA, Jones Cole LK. Rurality and birth outcomes: Findings from Southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health, 25(2), 141-149, 2009.

9. Background We have also demonstrated the relative impact of smoking in relation to birth outcomes locally* Compared with other modifiable health behaviors, including nutrition, adequacy of prenatal care utilization, and the use of alcohol and illicit drugs, pregnancy smoking was the strongest predictor of a low birth weight delivery 9 * Bailey B, Byrom A. Factors predicting birth weight in a low-risk sample: The role of modifiable pregnancy health behaviors. Maternal Child Health Journal, 11, 173-179, 2007.

10. Background SIDS Ear infections Asthma & allergies Respiratory infections Growth restriction Cognitive delays and deficits Behavioral & emotional problems 10

11. Background Smoking is the most modifiable risk factor for poor birth outcomes Successful treatment of tobacco dependence can achieve: –20% reduction in low birth weight babies –17% decrease in preterm births –250g average birth weight increase –Significant reduction in associated health & developmental complications 11

12. Background 12 Other findings and recommendations: –Interventions need to be culturally appropriate – what works in one setting may not work in another; particular issue in setting where smoking is more acceptable –Interventions need to address issues beyond just smoking that may impede efforts to quit including mental health, social support, stress, practical needs, and IPV –Address potential relapse post-partum

13. Interviews with Local Prenatal Smokers Revealed: A strong preference for individual discussions with their health care provider rather than group support sessions Knowing the dangers of pregnancy smoking, but were still unable or unwilling to quit That their providers did discuss smoking with them, but that these discussions did not go far enough in helping them to quit smoking 13 Background

14. Background Until recently, little had been achieved in the way of organized efforts to address pregnancy smoking in Northeast Tennessee In January of 2007 Governor Bredesen’s office strengthened efforts to improve birth outcomes in this region and funded the Tennessee Intervention for Pregnant Smokers (TIPS) program for a 4-year period TIPS is a multi-faceted approach that aims to reduce pregnancy smoking rates and improve birth outcomes in 6 counties throughout NE TN 14 $ $ $

15. Description of TIPS The program involves: 1) Physician training in providing smoking cessation counseling as a routine part of prenatal care 2) Nurse training in providing smoking cessation counseling during prenatal care & inpatient services 3) Provision of prenatal case management services in practices 4) Provision of a hospital-based case manager for admitted high-risk women and those post-partum 5) Education and training programs for nursing students 6) Community-based information and education, including cessation workshops 7) Development and provision of self-help materials 8) Web page with educational information for providers and patients 9) Research opportunities for students 10) Program Evaluation 15

16. Prospective population includes pregnant women in the 6- county NE TN region who are: Current smokers Exposed to significant second hand smoke Former smokers ≤ 2 years smoke-free All eligible women are: Provided 5 A’s counseling by their prenatal care provider Given a TIPS self-help manual Asked to participate in research interviews Case Managers provide: Smoking cessation counseling & support Motivation to increase prenatal care utilization Referrals to other needed services Support for increasing social support and reducing life stressors including domestic violence and depression 16 Description of TIPS

17. TIPS Progress & Findings to Date 17 Two full-time Case Managers see patients at two area OB practices with high rates of pregnancy smoking An additional full-time Case Manager provides on-call services for patients from other practices who qualify for the project and are interested in meeting with a case manager; this case manager also provides services to pregnant inpatients at area hospitals

18. TIPS Progress & Findings to Date 18 At the end of Year 2 (March 2009), 1054 eligible women had been enrolled in the TIPS program Eligible women represented about 50% of prenatal patients at Case Manager practices Only 8% of eligible women declined to participate at some level Of the 1054, 688 had delivered by the end of Year 2 and are included in this report

19. TIPS Progress & Findings to Date 19 Of the participants who entered prenatal care as smokers (N=420, 61%): 20% had a least one quit attempt Smoking Status at Delivery*: 51% 41% 8% * Data from multiple modes of self-report and biochemical verification

20. TIPS Progress & Findings to Date 20 Of the participants with significant second hand smoke exposure Second Hand Smoke Exposure Status at Delivery: 47% 26% 17%

21. TIPS Progress & Findings to Date 21 Of the participants who quit smoking just prior to conception, or after learning they were pregnant (but before entry into prenatal care): 90% remained smoke-free throughout pregnancy

22. TIPS Progress & Findings to Date 22 What aspects of TIPS program participation were associated with smoking/smoke exposure reduction and cessation? Looked at many aspects of participation including number and timing of visits with a CM, and the type of information and assistance provided in those sessions

23. TIPS Progress & Findings to Date 23 Reduced Smoking Quit Smoking Attempted to Quit Smoking All Participants 51%8%20% CM mtg 1 st trimester 52%8%16% 2+ CM mtgs 55%9%28% 4+ CM mtgs 50%20%35% 2+ 5 A’s sessions 49%8%26% In-depth counseling 92%0%21%

24. TIPS Progress & Findings to Date 24 Reduced Smoking Quit Smoking Attempted to Quit Smoking All Participants 51%8%20% Used TIPS book 44%10%19% Info: stress reduction 71%4%13% Info: mental health 59%6%35% Info: relapse prevention 71%5%23% Info: cessation for others 62%8%24%

25. TIPS Progress & Findings to Date 25 Reduced Smoking Quit Smoking Attempted to Quit Smoking All Participants 51%8%20% Assistance with practical issues 60%7%21% Any outside referral 63%11%29% Referral: outside counseling 61%11%34% Referral: partner to HD 53%12%19%

26. TIPS Progress & Findings to Date 26 Continued Smoking Reduced Smoking Quit Smoking Birth weight6.68 lb6.76 lb7.18 lb Birth length19.3 in19.2 in19.9 in Preterm birth18.2%13.9%13.7% NICU admission9.1%4.8%7.7% Fetal/neonatal death6.3%4.6%0%

27. TIPS Progress & Findings to Date 27 NS-Continued SHS NS-Reduced/ Eliminated SHS Continued Smoking Quit Smoking Birth weight6.84 lb7.03 lb6.68 lb7.18 lb Birth length19.3 in19.6 in19.3 in19.9 in Preterm birth22.0%11.7%18.2%13.7% NICU admission21.4%8.7%9.1%7.7% Fetal/neonatal death5.7%4.7%6.3%0%

28. Conclusions and Implications 28 TIPS program, especially case management services, have been well received (8% refusal rate) Complete pregnancy smoking cessation rate of 8% is comparable to rates of other similar programs Program was highly effective at getting participants to reduce their level of smoking (over half) Program was effective at getting women to make at least one quit attempt (20%)

29. Conclusions and Implications 29 Program was very effective at getting women to reduce or eliminate SHS exposure (only one quarter continued at same rate) Program was highly effective at reducing smoking recidivism among recent quitters (90% remained smoke-free)

30. Conclusions and Implications 30 Factors associated with successful smoking cessation: 4+ case manager meetings Use of the TIPS book Outside referrals, including for partner

31. Conclusions and Implications 31 Factors associated with successful smoking reduction: In-depth counseling Information on stress reduction, relapse prevention, and cessation for others Assistance with practical issues Outside referrals, including for counseling

32. Conclusions and Implications 32 Factors associated with quit attempts: Multiple case manager meetings Two or more 5 A’s sessions Information on mental health issues and cessation for others Outside referrals, including for counseling

33. Conclusions and Implications 33 Factors unrelated to change in smoking behavior: Seeing a case manager in the first trimester Seeing a case manager only once An approach that involves repeated contact and multiple types of assistance is clearly best.

34. Conclusions and Implications 34 Women who quit smoking during pregnancy see substantially improved birth outcomes over those who continue to smoke Even women who reduce, but don’t quit smoking completely, see improved birth outcomes, especially in terms of decreased risk for PTB and associated outcomes

35. Conclusions and Implications 35 Initial data suggest that SHS exposure has a much larger impact on birth outcomes than previously reported Compared to babies of those who smoked early in pregnancy but quit, babies born to non-smokers with continued significant SHS exposure were: 6 ounces lighter more than half an inch shorter almost twice as likely to be born preterm three times more likely to be admitted to the NICU

36. Conclusions and Implications 36 Recent program modifications: Focus on multiple contacts Provision of multiple and varied services Greater focus on reducing/eliminating second hand smoke exposure While cessation is ultimate goal, enhanced focus on smoking reduction among those unwilling to quit

37. Final Word 37 Efforts to reduce pregnancy smoking/smoke exposure can be effective and lead to substantial improvements in birth outcomes To be successful, programs should also address environmental and lifestyle factors that contribute to smoking/smoke exposure continuation

38. Select Resources American College of Obstetricians and Gynecologists (www.acog.org)www.acog.org TIPS Online (www.etsu.edu/TIPS)www.etsu.edu/TIPS Smoke-Free Families (www.smokefreefamilies.org)www.smokefreefamilies.org Treating Tobacco Use and Dependence Agency for Healthcare Research and Quality (www.ahrq.gov)www.ahrq.gov 38

39. Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data from the First Two Years of TIPS Beth A. Bailey, PhD Associate Professor of Family Medicine Director, Tennessee Intervention for Pregnant Smokers East Tennessee State University