Kansas Public Health Nursing and Maternal Child Health Annual Conference May 3 – 5, 2005

1. Kansas Public Health Nursing and Maternal Child Health Annual ConferenceMay 3 – 5, 2005 Treating Tobacco Use During Pregnancy and Beyond: The “5 A’s” Becky Tuttle, MA Outreach Coordinator Tobacco Use Prevention Program Kansas Department of Health and Environment Kansas Tobacco Quitline 1-866-KAN-STOP

2. Ways to Help Pregnant Smokers Quit • Offering help through the healthcare system • Use of media • Research, evaluation, and surveillance • Policy • Price of tobacco products • Reimbursement for treatment • Tobacco-free environments • Community and worksite interventions

3. Spontaneous Quitting and Maintenance of Cessation Research has helped us to identify those most likely to quit on her own: • Higher income/education • Married or have partners • Having first child • Having a wanted pregnancy • Entering prenatal care early

4. Spontaneous Quitting and Maintenance of Cessation Research has helped us to identify those most likely to quit on her own: • Experiencing nausea during first trimester • Intending to breastfeed • Are light to moderate smokers • With fewer smokers in their social circle • With stronger belief that smoking can harm their developing baby

5. The “5 A’s” Approach to Tobacco Cessation • A 5-step tobacco intervention proven effective for pregnant women • Consistent with the strategies developed by the National Cancer Institute, the American Medical Association and others • Adapted for pregnant women by ACOG

6. Intervention Makes a Difference • 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 during pregnancy than at any other time in her life

7. Conclusions for Behavioral Intervention Studies • Pregnancy is a good time to intervene • Brief counseling works better than simple advise to quit • Counseling with self-help materials offered by a trained clinician can improve cessation rates by 30% to 70% • Intervention works best for moderate (less than 20 cigarettes per day) smokers

8. The “5 A’s” • Askabout tobacco use • Advise to quit • Assess willingness to make a quit attempt • Assist in quit attempt • Arrange follow-up

9. Step 1: Ask – 1 Minute Which of the following statements best describes your cigarette smoking? • I have never smoked or have smoked fewer than 100 cigarettes in my life. • I stopped smoking before I found out I was pregnant and am not smoking now. • I stopped smoking after I found out I was pregnant and I am not smoking now. • I smoke some now but have cut down since I found out I was pregnant. • I smoke about the same amount now as I did before I found out I was pregnant.

10. Step 2: Advise – 1 Minute Clear, strong, personalized advise to quit Clear: “My best advise for you and your baby is for you to quite smoking.” Strong: “As your clinician, I need to you to know that quitting smoking is the most important thing you can do to protect your baby and your own health.” Personalized: Impact of smoking on the baby, the family, and the patient’s well being.

11. Step 3: Assess – 1 Minute • Asses the patient’s willingness to quit within the next 30 days. • If a patient responds that she would like to quit within the next 30 days, move on the Assist step. • If a patient does not want to try to quit, use the “5 R’s” to try to increase her motivation.

12. Step 4: Assist – 3+ Minutes • Suggest and encourage the use of problem-solving methods and skills for tobacco cessation. • Provide social support as part of the treatment. • Arrange social support in the smoker’s environment. • Provide pregnancy-specific self-help smoking cessation materials.

13. Strategies Some Women Find Helpful • Set a quit date within 30 days and sign a contact. • Develop approaches to manage withdrawal systems • Remove all tobacco products from her home • Decide what to do in situations in which she usually smokes

14. Step 5: Arrange - 1+ Minute • Follow up to monitor progress and provide support • Encourage the patient • Express willingness to help • Ask about concerns or difficulties • Invite her to talk about her success

15. Patients Who Decline to Quit Using the “5 R’s” • Relevance • Risks • Rewards • Roadblocks • Repetition

16. The “5 R’s” - Rewards • Your baby will get more oxygen after just one day • Your clothes and hair will smell better • You will have more money • Food will taste better • You will have more energy

17. The “5 R’s” - Roadblocks • Negative moods • Being around other smokers • Triggers and cravings • Time pressures

18. Overcoming Roadblocks:Negative Moods • Suck on hard candy • Engage in physical activity • Express yourself (write, talk, etc.) • Relax • Think about pleasant, positive things • Ask others for support

19. Overcoming Roadblocks:Other Smokers • Ask a friend or relative to quit with you • Ask others not to smoke around you • Assign nonsmoking areas • Leave the room when others smoke • Keep hands and mouth busy

20. Intervention Effectiveness The “5 A’s” counseling approach can increase quit rates among pregnant smokers by 30% to 70%.

21. Postpartum Relapse Prevention Predictors of Relapse • Concerns about weight gain • Intention to quit and self-efficacy • Intention to breastfeed • Smoking behavior of family and friends

22. Postpartum Relapse Prevention Strategies • Focus on benefits of quitting for women • Highlight harms associated with secondhand smoke for baby • Begin relapse prevention counseling and skill building toward the end of pregnancy

23. QUESTIONS??? CONTACT INFORMATION: Becky Tuttle, MA Outreach Coordinator Tobacco Use Prevention Program Kansas Department of Health and Environment 130 South Market, Suite 6050 Wichita, KS 67202 316.337.6056 btuttle@kdhe.state.ks.us