1. House Calls: Addressing Disparities in Cessation Access for Low Income Pregnant and Parenting Women Ingham County Health Dept. NACCHO Webinar May 1, 2009

2. Challenges identified by clients – Belief that the program would not help – Lack of support to quit at home – Too busy to participate – Lack of transportation – Lack of child care – Smoking cessation not a priority

3. House Calls Goals Develop comprehensive, sustainable home- based tobacco use treatment for pregnant and parenting women seeking services at the ICHD Increase the number of pregnant and parenting women who engage in tobacco use treatment and successfully stop smoking Increase the number of women who remain tobacco-free during the postpartum period

4. Beginning with the end in mind Builds tobacco use treatment into current service delivery system at ICHD Capitalizes on relationships already established with Public Health Advocates and Public Health Nurses

5. What services are provided? Cessation support during regular home visits Education about the effects of tobacco Incentives – House Calls welcome gift – $20 gift card monthly for participating – Additional $20 gift card with confirmed tobacco-free status (self report AND < 6 CO)

6. Testing and Data Collection Information gathered on smoking history, current use, and interest in stopping smoking Participants complete carbon monoxide test specifically designed for tobacco treatment to verify tobacco-free status Participants provide random saliva cotinine test at least once during program

7. Our intervention is based on Education and support Reasoned actions ( people do what they do because it makes sense to them in some way) Cost benefit analysis ( increase the costs of smoking and increase the benefits of not smoking) Problem-solving

8. Our approach depends on Asking permission Using I statements Repetition, repetition, repetition Offering empathy Building on established, trusting relationships A mutual expert model

9. Our activities with clients include Educating about the dangers of tobacco Encouraging them to postpone nicotine use Teaching task containment (vacations from smoking) Helping them problem solve Providing support for their efforts

10. Our tools for client education include Toxic chemical bag – Rat – Nail polish remover – Industrial solvent – Toy car – Brush – Packing bubbles – Molasses Artificial lungs

12. Our successes thus far 50 women projected to enroll in House Calls 89 women currently enrolled Increased community capacity to provide cessation support for low-income women Working relationships between PHNs and PHAs strengthened

13. Lessons learned – Incentives open the door for conversations – CO monitors are a huge helpwomen love to see their numbers to down – Home- based support works well – Pre-existing relationships make a difference – Support offered to other family members is vital – Accessible TA for staff is helpful and empowering – Tobacco use treatment embedded in other issues – Multiple points of contacta classic public health approach

14. Planning for sustainability Sustainability a primary concern intervention integrated into ongoing work Incentives to be reduced during second year to make the program more sustainable Investigating setting up a fund with the Community Foundation to cover incentives

15. Suggestions for other LHDs Rethink tobacco use message: – Focus on women not consuming nicotine during pregnancy – Encourage to take smoking breaks for the baby – Advise to inhale smoke less deeply – Support in cutting down on the number of cigarettes consumed Do not rely on the patients readiness to quit in determining the intervention Discuss neurobehavioral complications and long term consequences of tobacco use in a meaningful context

16. Suggestions for LHDs, continued Combine empathy and direct advice Use motivational interviewing techniques – Chair analogy (value, knowledge, skills, and support) – ICR ruler Provide problem-solving and ongoing positive support Emphasize harm reduction for those unable to quit

17. More suggestions for LHDs Reframe the message to focus on attainable goals – not consuming tobacco during pregnancy vs. quitting smoking Provide ongoing support to women who quit during pregnancy (80% + return to smoking without support) Make referrals to appropriate programs for others in the home who smoke

18. A parting thought… You may never know what results come from your action. But if you do nothing, there will be no result. Mohandas Ghandi

19. Thank You! Ingham County Health Department Renée Canady, Deputy Health Officer, rcanady@ingham.org (517-887-4466)rcanady@ingham.org Melany Mack, Dir. Public Health Services, mmack@ingham.org (517-887-4568)mmack@ingham.org Tiffany Doolittle, Public Health Nurse, tdoolittle@ingham.org (517-887-4470)tdoolittle@ingham.org Sarah Kenney, Public Health Advocate, skenney@ingham.org (517-272-4123)skenney@ingham.org