Smoking Cessation During Pregnancy

1. Smoking Cessation During Pregnancy Healthy Start & The SCRIPT Program September 14, 2012

2. Welcome & Overview • Purpose • To provide the MCH community with an overview of the SCRIPT Program, and to learn how the program can be implemented in Healthy Start sites and the community to reduce the rates of smoking during pregnancy. • Agenda • Overview of the SCRIPT Program • Implementation of SCRIPT in West Virginia • Discuss SCRIPT Training Opportunities • Question & Answer Period • Presenter Introductions

3. Our Presenters Deborah Gordon-Messer, MPH Editorial & Project Manager, SOPHE Jeannie Clark, RN, ASN, BA, BSN Director of Perinatal Program, WV Department of Health & Human Resources, Bureau of Public Health, Office of Maternal, Child & Family Health Penny Womeldorff, MA, LSW Project Director, WV Healthy Start/HAPI Project

4. Changing Health Systems to Support Smoking Cessation Among Pregnant Women Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Deborah Gordon-Messer Society for Public Health Education September 14, 2012

5. Preventable Cause of Fetal and Infant Morbidity and Mortality Active smoking during pregnancy has been defined as the most serious and preventable cause of fetal and infant morbidity and mortality by the U.S. Healthy People Objectives for the Nation.

6. The Problem: Smoking Rates and Trends in the United States Although rates are decreasing, an estimated 22% of women of reproductive age continued to smoke in 2006. During 2000-2004: • ~174,000 women died annually from smoking-attributable causes • ~776 infants died annually from causes attributed to smoking during pregnancy

7. The Problem: Smoking Rates and Trends in the United States • Although the proportion of women who report smoking during pregnancy has dropped substantially, wide disparities exist by race/ethnicity, and maternal education. 

8. MCH Smoking Health Disparities Differences by Age A higher percentage of young women ages 15 to 24 smoke during pregnancy than among women 25 years and older. • 12.6% ages 15 to 19 • 14.5% ages 20 to 24 • <10 % ages 25 and older Differences by Mother’s Education • 17.9% - 9 to 11 yrs of education • 1.2 % - 16 yrs of education or more

9. MCH Smoking Health Disparities Differences by Race and Hispanic Origin • 16% American Indian or Alaska Native mothers • 10 % white mothers • 9% black mothers • 1% Asian or Pacific Islander mothers • 2 % Hispanic mothers • Sizeable variations in smoking rates among subgroups of Hispanic women • 0.7% or Central and South American mothers • 9.1% for Puerto Rican mothers

10. Healthy People 2020 Objectives for the Nation Goal: Improve the health and well-being of women, infants, children and families. Morbidity and Mortality • Reduce the rate of fetal and infant deaths • Reduce the rate of maternal mortality • Reduce maternal illness and complications due to pregnancy • Reduce cesarean births among low-risk women • Reduce low birth weight (LBW) and very low birth weight • Reduce preterm births

11. Healthy People 2020 Objectives for the Nation Pregnancy Health and Behaviors • Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women Postpartum Health and Behavior • (Developmental) Reduce postpartum relapse of smoking among women who quit smoking during pregnancy

12. The Solution: SCRIPT • An award-winning, evidence-based program shown to be effective in helping thousands of pregnant women quit smoking. • Designed to be a component of a patient education program for prenatal care providers. • Cited by the Agency for Healthcare Research & Quality’s Smoking Cessation Clinical Practice Guidelines.

13. Acknowledgments Richard Windsor, MS, PhD, MPH • Developer of the SCRIPT program • Professor of Public Health, The George Washington University. • PI of 8 NIH/DHHS peer reviewed/funded SCRIPT evaluation studies (Windsor, et al, 1982-2012). • Published extensively on the acceptability, effectiveness, and cost effectiveness of this evidence-based program.

14. The SCRIPT Program • An integrated component of a patient education program for prenatal care providers. • Educates a pregnant woman about why she should quit or reduce her smoking for her health and the health of her baby. • Provides an in-depth look at the evidence-based, “best practice” procedures developed for screening, intervention, and follow-up.

15. SCRIPT Intervention Components • “A Pregnant Woman’s Guide to Quit Smoking” (the Guide) • “Commit to Quit Smoking During and After Pregnancy” (the Video) • Comprehensive counseling to quit or significantly reduce smoking during pregnancy • Follow up and counseling to encourage or maintain smoking cessation

16. A Pregnant Woman’s Guide to Quit Smoking (the Guide) A 40-page, tailored guide that outlines a self-evaluation process to help build women’s smoking cessation success over a seven-day period. Written in the 5-6th grade reading level.

17. Commit to Quit Video • The video was developed to: • Enhance the patient’s motivation to quit smoking. • Ensure patient exposure to recommended smoking cessation skills. • Significantly reduce counseling time. The video presents: • Strong visual and personal verbal messages about maternal, fetal, and infant risk. • Testimonials of pregnant smokers who had quit smoking. • The demonstration of behavioral skills to quit smoking.

18. Comprehensive Patient Counseling in SCRIPT: • Introduces the SCRIPT Intervention and explains the purpose of the Guide and Video • ASKS the patient how many cigarettes she smokes in a day • ASSESSES the patient’s readiness to quit and beliefs about risk of tobacco exposure • ADVISES the importance of quitting smoking during pregnancy • ASSISTS with quitting efforts by watching the Video and going through days 1-4 of the Guide

19. Follow up to Encourage or Maintain Smoking Cessation • ARRANGE the next appointment and follow up to reinforce cessation messages • Follow up can include a telephone reinforcement call and/or a follow up visit. Counseling and Follow Up Incorporate the “5 A’s”

20. SCRIPT: An Effective Program • The effectiveness of the SCRIPT Program has been rigorously demonstrated (1982-2008). • The acceptability of the Program by prenatal clients, the routine delivery by prenatal care staff, and the cost effectiveness of implementing SCRIPT have been demonstrated by independent evaluations in • Alabama • North Carolina • Ohio • Canada • Other Countries

21. Ordering SCRIPT Materials Society for Public Health Education 10 G St, NE, #605 Washington, DC 20002 Call: 202-408-9804 Website:http://www.sophe.org/Sophe_Resources.cfm

22. Perinatal Programs Jeannie Clark, RN, ASN, BA, BSN, Director Sponsored in part by Title V, MCHB Block Grant Funding

23. Perinatal Programs • Right From The Start Program • Maternity Services • Birth Score Program • SCRIPT (Smoking Cessation/Reduction in Pregnancy Treatment) • Newborn Hearing Screening

24. Right From The Start Program Started in 1988 Statewide initiative Home-based case management services Government sponsored pregnant women Incomes at 185% of the FPL Medicaid eligible at risk infants up to one year of age All pregnant teens age 19 and under regardless of income Non-citizens Pregnant women uninsured or underinsured for obstetrical care

25. Components of Right From The Start • Provider Recruitment and Training • In-home Care Coordination • Education (Partners for a Healthy Baby curriculum developed by FSU) • Maternity Services • Birth Scoring • Newborn Hearing Screening • Quality Assurance Monitoring

26. Goals • Access to early and adequate prenatal care • Decreased number of preterm births in WV • Reduction in low birth weight births in WV • Reduction in infant mortality in WV • Reduction in the number of pregnant smokers in WV • Reduction of environmental exposure to second hand cigarette smoke • Improvement in overall health of individuals, families and infants in WV • Empowerment to access services after case closure

27. RFTS Providers Regional Map • 8 Regional Care Coordinators (RCCs) • 169 Designated Care Coordinators (DCCs)

28. Case Management Services • Coordination of medical care • In home support • Enhancements to medical care • Providers are Registered Nurses and Licensed Social Workers • Prenatal patients up to 60 days postpartum • Infants up to age 1 year

29. Components of Case Management • Personalized in-home assessment • Individually designed care plan • Referrals as necessary • Follow-up • Monitoring • Educational activities • Family planning • Empowerment • Preventive self care • Support • Depression Screening • Transportation assistance

30. West Virginia Right From The Start SCRIPT Smoking Cessation/Reduction In Pregnancy Treatment

31. What is SCRIPT? • Evidence-based smoking cessation in pregnancy program developed by Dr. Richard Windsor • Implemented in WV January 2002 through the Office of Maternal, Child and Family Health Right From The Start (RFTS) Program; also in HAPI Project • WV pregnant women needed a stop smoking “prescription treatment” • WV ranks among the highest in U.S. with smoking during pregnancy (27.2%)* • National rate of 9.7% in 2008* • 40.4% are WV Medicaid pregnant smokers* • Awarded 4 year grant (2007-2011) through NCI-NIH • Purpose - to evaluate the effectiveness of an evidence- based tobacco treatment program provided by Designated Care Coordinators in a home-based setting • *West Virginia Vital Statistics 2009 Data

32. SCRIPT • SCRIPT implemented through routine RFTS DCC home-visits and protocols established in the current RFTS Program • Smoking status reviewed during screening and follow-up visits with all prenatal clients • Intervention available to all pregnant smokers wanting to quit or reduce (available same day as screening) • Counseling/education provided • Carbon monoxide values obtained • Established curriculum used • A Pregnant Woman’s Guide to Quit Smoking • Commit to Quit DVD • 5A’s Best Practice Methods • Referral made to WV Quitline

33. The Core SCRIPT Procedures • Component #1: Commit to Quit Smoking During & After Pregnancy Video (10 Min.) • Component #2: A Pregnant Women’s Guide to Quit Smoking (5th-6th grade level) • Component #3: Patient-centered counseling session (10-15 Minutes)

34. The 5A’s ASK Abouttobacco use Tobacco users to quit ADVISE Readiness to quit ASSESS With the quit attempt ASSIST Follow-up care ARRANGE

35. Follow up home visit made within 1-2 weeks • Assess clients readiness to quit or decrease • If ready, proceed with 7 day quit plan in guide • If quit or cut down, congratulate, support, show video, give educational materials, schedule follow up visit/phone calls • If refuses, leave educational materials and reassess at next contact • Reassess by using Tobacco Screening Follow Up Form prior to delivery and again prior to case closure • CO testing time frames are flexible and up to the discretion of the Care Coordinator and/or client

36. Goals • Improvement in overall health of individuals, families and infants in WV • Reduction in low birth weight births in WV • Decreased number of preterm births in WV • Reduction in the number of pregnant smokers in WV • Reduction of environmental exposure to second hand cigarette smoke • Reduction in infant mortality in WV

37. SCRIPT Dissemination Program Evaluation Aims • Aim #1: To conduct an Effectiveness Evaluation to document the cessation and significant reduction (SR) rates attributable to SCRIPT delivered by DCC’s to RFTS pregnant smokers (2006-07 vs 2009-10). • Aim #2: To conduct a Process Evaluation to document the level of fidelity of SCRIPT procedures delivered by DCCs to RFTS pregnant smokers, and to confirm the RFTS-SCRIPT Project Adoption Rate in 2009-10.

38. Challenges • > 20% of DCC’s were not implementing SCRIPT with fidelity - RFTS clients who wanted SCRIPT did not receive it. • Because RFTS enrollment is voluntary, lag time between RFTS contact and screening visit by a DCC was typically three months. • The typical RFTS client received SCRIPT three months later than a clinic-based smoker: 2nd or 3rd trimester. • Smokers who remained were the most addicted, had the highest home ETS rates, and had the lowest levels of psycho-social support and motivation to quit.

39. SCRIPT Effectiveness • Institutionalization of SCRIPT into the RFTS Program has been achieved: The RFTS + NIH Objective. • Study results provide valid, empirical evidence that an additional proportion of women, even very late in pregnancy, can be helped by trained nurses and social workers to change their smoking behavior. • Recognition of life challenges for RFTS clients and implementation challenges for DCC’s- Primary Care

44. West Virginia Department of Health and Human Resources Bureau For Public Health Office of Maternal Child and Family Health Room 427, 350 Capitol Street Charleston, WV 25301 Jeannie Clark, RN, BA, BSN Director, Perinatal Programs 1-800-642-8522 304-558-5388 Fax 304-558-7164 Email: jeannie.m.clark@wv.gov Website: www.wvdhhr.org/rfts

45. WV Healthy Start/ HAPI Project Department of Obstetrics and Gynecology WV Healthy Start/HAPI Project(Helping Appalachian Parents and Infants)AND the Right From the Start Program Project Overview Penny Womeldorff, Project Director September 14, 2012

46. WV Healthy Start/HAPI Project Overview – HAPI Project • One of 105 federally funded Healthy Start Projects (HRSA/MCHB) • Initially funded in July 2001 • Administered through the WVU Department of Ob/Gyn and WVU Research Corporation • The only Healthy Start Project in WV

47. WV Healthy Start/HAPI ProjectTarget Area/Population • Mothers of Medicaid (low-income) High Birth Score and NICU infants and low-income pregnant women • Infant Mortality Rate of 13.6 (per 1000 births) for 2002-2004 • Mothers with infants up to two years old with multiple risk factors (such as substance use, depression, domestic violence, smoking, no contraceptive use, etc.) • Target Area – eight counties in North Central WV • Barbour • Harrison • Marion • Monongalia • Preston • Randolph • Taylor • Upshur

48. WV Healthy Start/HAPI ProjectService Delivery/Administration • Services integrated with WV Office of Maternal, Child, and Family Health (OMCFH) Title V program, Right From the Start (RFTS home visitation) • Share staff, protocols and resources • Maximizes the use of state and federal resources • Simultaneous enrollment in HAPI and RFTS allow the blending of resources to provide a comprehensive package of services that would otherwise be unavailable to women, infants and families

49. WV Healthy Start/HAPI ProjectService Delivery/Administration • All required core services for Healthy Start are provided by local RFTS Designated Care Coordinators (nurses and social workers) and Outreach Workers (former consumers), and are delivered in conjunction with existing RFTS Project services • Currently have 27 DCCs and 3 Outreach Workers • Requires ongoing collaboration between programs for effective integration

50. WV Healthy Start/HAPI ProjectHealthy Start Service Components • 9 Required Service Components • Core Services • Outreach and Recruitment • Health Education • Case Management • Interconceptional Services • Depression Screening and Referral • Core Systems and Efforts • Local Health System Action Plan • Consortium • Sustainability • Linkage/Collaboration with Title V