A Clinician’s Guide to Helping
Pregnant Women Quit Smoking:
Using the 5 A’s
Tennessee Intervention for
Pregnant Smokers (TIPS)
The American College of
Obstetricians and Gynecologists
TIPS funded by
Tennessee Governor Phil Bredesen’s Office of Children’s Care Coordination
Portions of this presentation © 2002 The American College of Obstetricians and Gynecologists
Pregnancy Smoking in NE TN
U.S. % TN % NE TN%
2
Pregnancy smoking rate 12.6% 17.1%
49.0%
LBW rate
7.9%
9.4%
10.6%
Preterm birth rate
12.3% 14.1%
16.1%
Summary of Pregnancy Risks Associated
with Smoking & Smoke Exposure
(Local and National Findings)
• Ectopic pregnancy
• Intrauterine growth
restriction
• Placenta previa
• Abruptio placentae
• PROM
• Spontaneous abortion
• Preterm delivery
3
Postnatal Risks Associated with a
Smoke-Exposed Pregnancy
(Local and National Findings)
•
•
•
•
•
•
•
4
SIDS
Ear Infections
Asthma & Allergies
Respiratory Infections
Growth Restriction
Attention Problems
Behavioral &
Emotional Problems
Risks Associated With Secondhand
Smoke Exposure
• Slowed Fetal Growth
• Higher Heart Rates (2-4wks)
• Increased Rates of:
Miscarriage
 Preterm Delivery
 Low Birth Weight
 Conduct Problems (5-7yrs)

5
Effects were present even when
controlling for maternal
smoking.
Intervention Makes a Difference:
Birth Outcomes
• Smoking is the most modifiable risk factor for
poor birth outcomes
• Successful treatment of tobacco dependence
can achieve:
–
–
–
–
6
20% reduction in low-birth-weight babies
17% decrease in preterm births
250g average birth weight increase
Significant reduction in associated health &
developmental complications
Intervention Makes a Difference:
Smoking Rates
• When compared to simple advice to quit,
the use of brief interventions has more than
doubled quit rates:
Study
UC
BI
Hegaard et al., 20031
5%
14%
Windsor et al., 20002
8.8%
17.3%
• Brief counseling + provision of self-help
materials by a trained clinician, increases
cessation rates up to 70%
7
Pregnancy Smoking in NE TN
Patients Reported:
 Knowing the dangers of pregnancy smoking, but
remained unwilling or unable to quit
 A strong preference for individual discussions
with their health care provider rather than group
support sessions
 That their providers did discuss smoking with
them, but that these discussions did not go far
enough in helping them to quit smoking
8
About TIPS
• TIPS funded in January of 2007 for a 4 year
period
• The project involves 2 components:
1)
2)
Service Provision (Physician-Based Brief Intervention
& Prenatal Case Management)
Program Evaluation
• Prospective Population Includes Pregnant Women
Who Are:
– Current Smokers
– Exposed to Significant Secondhand Smoke
– Former Smokers ≤ 2 Years Smoke-Free
9
About TIPS : Service Provision
• Approximately ½ of the women will receive
additional Case Management Services
• Case Managers will provide:
•
•
•
•
Additional support of smoking cessation efforts
Motivation to increase prenatal care utilization
Referrals to other needed services
Support for the reduction of life stressors including
domestic violence and depression
• Patients will also receive a TIPS Self-Help
Resource Guide
10
• Patients will be asked to participate in research
interviews
About TIPS: The Research
• Program Evaluation Includes:
•
•
•
•
Physician Documentation of All BI Encounters
Evaluation of Medical Records
Evaluation of Delivery & Newborn Chart Information
1-on-1 Case Manager Conducted In-depth Patient
Interviews
• Findings Used To:
•
•
•
•
11
Validate Provided Services
Modify and Improve Services
Conduct Cost-Benefit Analysis
Inform the Development and Implementation of the
TIPS Program on a Larger Scale
The Physician’s Role in TIPS
12
5 A’s Approach
to Smoking Cessation
• A 5-step smoking
intervention proven effective
for pregnant women
• Consistent with strategies
developed by the National
Cancer Institute, the
American Medical
Association, and others
• Adapted for pregnant women
by ACOG
13
The 5 A’s
1. ASK about tobacco use
2. ADVISE to quit
3. ASSESS willingness to make a quit attempt
4. ASSIST in quit attempt
14
5. ARRANGE follow-up
Integrating the 5 A’s into the
TIPS Program
Step 1. At INITIAL prenatal visit, ask every patient
about Smoking and Smoke Exposure
Step 2. Implement the 5 A’s at EVERY visit
involving a smoke-exposed pregnancy
Step 3. Document All Encounters:
15
•
•
•
•
•
ACOG/Pre-OB documentation
Physician documentation form & graph
Provides feedback to you & your patient
For Medicaid reimbursement
Provides additional data
PRE-OB Documentation:
Alternate ACOG Tobacco Use Questions
• Located on ACOG & completed in the place of traditional Tobacco
16
•
Use question #14 on Form A
EVERY PATIENT is asked the alternate set of questions
Physician 5A’s Documentation Form
17
ASK — 1 Minute
Which of the following statements
best describes your current smoking habits?
You have
never
smoked or
have smoked
fewer than
100
cigarettes in
your
lifetime.
18
You stopped
smoking
before you
found out you
were
pregnant and
are not
smoking now.
You stopped
smoking after
you found out
you were
pregnant and
are not
smoking now.
Congratulate
Patient
You smoke
some now
but have cut
down since
you found
out you were
pregnant.
You smoke
about the
same amount
now as you
did before you
found out you
were
pregnant.
Advise
ASK — 1 Minute
Which of the following best describes your
exposure to other people smoking?
You do not
have regular
contact with
anyone who
smokes.
19
You have
regular
contact (but
do not live)
with other
people who
smoke, but
they DO NOT
smoke
around you.
Congratulate
Patient
You have
regular
contact (but
do not live)
with other
people who
smoke, and
they DO often
smoke when
you are
around.
You live
with at least
1 smoker,
but they DO
NOT smoke
when you
are around.
You live with
at least 1
smoker, and
they DO often
smoke when
you are
around.
Advise
ASK: Documentation
20
ADVISE — 1 Minute
• Clear, strong, personalized advice to quit:
21
– Clear & Strong: “As your clinician,
my best advice for you and your
baby is for you to quit
smoking and reduce your
second-hand smoke exposure. I
need you to know that quitting is
the most important thing you can
do to protect your baby and
improve your own health.”
– Personalized: Impact of smoking
on the baby, the family, and the
patient’s well being
ADVISE: Documentation
22
ASSESS — 1 Minute
• Assess the patient’s willingness to quit
within the next 30 days.
• If a patient responds that she would like to
try to quit within the next 30 days, move on
to the Assist step.
• If the patient does not want to try to quit, try
to increase her motivation via education and
personalizing the issue.
23
ASSESS — 1 Minute
ASK:
“How WILLING are you to quit smoking in the next 30 days?”
I---------I----------I----------I----------I---------I----------I----------I---------I----------I----------I
0
1
2
3
4
5
6
7
8
9
10
Not At All
Moderately
Extremely
Willing
Willing
Willing
ASK:
“What would it take to make you more willing to quit, to get
you to move from your score to a score 3 pts higher on the
scale?”
24
ASSESS: Documentation
25
ASSIST — 3+ Minutes
Initial Considerations
• Addiction has both PHYSICAL &
BEHAVIORAL components
• Both factors must be addressed for
successful cessation
• ASSIST techniques should be chosen in
accordance with patient’s willingness to quit
26
Basic Strategies Some Women
Find Helpful
 Remove all tobacco products from her home
 Identify triggers & roadblocks
 Determine what she can do in situations in
which she usually smokes
 Develop approaches to manage withdrawal
symptoms
 Plan ways to handle others smoking
around her
27
Basic Strategies Some Women Find
Helpful – cont.
 Discuss the dangers of secondhand smoke
 Identify & arrange social support
 Complete quit date contract
28
Specific Methods of Assisting
Provide Pregnancy-Specific Smoking Cessation
Self-Help Materials:
29
• Health Hazards For The Baby
• Health Benefits Timeline
• Identify Personal Barriers
& Potential Triggers
• Patient Identified Personal
Benefits To Quitting
• Withdrawal Symptoms:
Cravings And Coping Skills
• Cost Savings & Suggest Personal
Rewards
• Alternative Ways to Cope
& Manage Stress
Additional Assist Components:
Addressing Varying Susceptibility
• Have you ever heard:


“I smoked with my first child and s/he was OK!”
“My mom smoked with me and I turned out OK!”
• Talk with your patient about varying susceptibility
• Circumstances that vary between pregnancies may
significantly impact the degree to which the fetus
will be harmed by smoking:
30
–
–
–
–
–
–
Overall amount of primary & secondary smoke exposure
Stress
Nutrition
Increased age during pregnancy
Environmental factors
Overall health
Additional Assist Components:
Pharmacologic Intervention
• Behavioral intervention is the first-line treatment for
pregnant women
• Pharmacotherapy can be considered for heavy
smokers unable to quit via behavioral interventions
alone
• Very limited data on the safety or effectiveness of
pharmacologic treatments in pregnant women
31
Additional Assist Components:
Pharmacologic Intervention
• If used:
 An intermittent delivery system should be used
 Administered at lowest effective range
 Recommended that blood levels of nicotine should be
monitored
• Pharmacotherapy is a safe alternative for family
members to decrease secondhand smoke
exposure
32
Additional Assist Components:
Pharmacologic Intervention
33
Class C
Class D
• Nicotine polacrilex
gum, lozenges
• Varenicline (Chantix)
• Bupropion extended
release (Zyban,
Wellbutrin)
• Clonidine
• Nicotine transdermal
patches
• Nicotine nasal spray
• Nicotine vapor inhaler
• Nortriptyline
ASSIST: Documentation
34
ARRANGE — 1+ Minute
•
•
•
•
•
•
Follow up to monitor progress and provide support
Encourage the patient
Ask about concerns or difficulties
Invite her to talk about her successes
Express willingness to help
Offer referrals to the Smoking Quit Lines, local
Health Departments, your TIPS Case Manager, etc.
ARRANGE for a Follow-Up: Documentation
35
Additional Sections of TIPS
Documentation Form
36
Reimbursement Coding
• ICD-9-CM code 305.1 (tobacco use
disorder, tobacco dependence)
AND
• CPT code 99401 (15-minute physicianprovided counseling)
– with modifier 25 as part of regular prenatal visit
OR
• CPT code 99211 (nurse counseling)
37
38
Summary of Tasks for TIPS
Program – cont.
Step 4. Refer Any of the Following Patients to your
TIPS Case Manager:



Current Smoker
Anyone Regularly Exposed to Second Hand Smoke
Former Smoker ≤ 2 Years Smoke-Free
Step 5. Provide TIPS Smoking Cessation Guide To
All OB Patients In Above Categories
39
Sample Contents:
What Is In A Cigarette
• One Cigarette Contains Over 4,000 Chemicals!
• The Overwhelming Majority of These Chemicals Have Been
Shown to be Carcinogenic!
Some Of The Over 4,000 Chemicals In A Cigarette
40
Acrolein
Toxic Liquid with
Cancerous Vapors
Hexamine
Barbecue Lighter
Cadmium
Rechargeable Batteries
Nitrous Oxide Phenols
Disinfectant
Acetone
Nail Polish Remover
Hydrogen Cyanide
Gas Chamber Poison
Pyridyne
Water Repellents,
Bactericides, &
Herbicides
Propionaldehyde
Chemical Disinfectant,
Preservative
Plastic , & Rubber
Acetic Acid
Vinegar
Methanol
Antifreeze & Rocket Fuel
DDT/Dieldrin
Insecticides & Bug Sprays
Carbon Monoxide
Car Exhaust Fumes
Ammonia
Floor/Toilet Cleaner
Napthalene
Mothballs
Ethanol
Alcohol
Stearic Acid
Candle Wax & Fireworks
Arsenic
Poison used in Making
Insecticides
Nicotine
Insecticide/ Addictive Drug
Formaldehyde
Preserver-Body
Tissue & Fabric
Toluene
Industrial Solvent
Butane
Cigarette Lighter Fluid
Nitrobenzene
Gasoline Additive
Formic Acid
Gas Used in Making
Pesticides & Textiles
Vinyl Chloride
Makes PVC
Sample Contents:
Timing of Health Benefits
20 minutes
Blood pressure, heart rate return to
normal
8 hours
O2 level returns to normal; nicotine
and CO levels reduced by half
2 to 12 weeks
Circulation improves
3 to 9 months
Lung function increases by up to
10%; coughing, wheezing,
breathing problems reduced
24 hours
CO is eliminated from body; lungs
begin to eliminate mucus, debris
41
1 year
Heart attack risk halved
48 hours
Nicotine eliminated from body; taste
and smell improve
10 years
Lung cancer risk halved
72 hours
Breathing is easier; bronchial tubes
relax; energy levels increase
15 years
Heart attack risk same as for
someone who never smoked
1990 Surgeon General’s Report
Sample Contents:
Health Benefits for Both Mother & Child
THE BABY’S HEALTH
42
If She Quits While Pregnant,
Her Baby Will:
• Get more oxygen.
• Be protected from deadly carbon
monoxide and other carcinogens
• Have fewer health problems such
as asthma, wheezing, colds, ear
infections, etc.
• Be more likely to be born at a
healthy size and weight.
• Cough and cry less.
• Be less likely to develop chronic
lifelong disabilities
• Have fewer doctor visits.
• Likely have fewer behavioral or
attention problems later in life.
• Be less likely to die of prenatal
complications & SIDS .
THE PATIENT’S HEALTH
If She Quits Smoking, She Will:
• Breathe easier & have more energy.
• Be less likely to have a
miscarriage, stillbirth or
spontaneous abortion.
• Decrease her chances of having a
heart attack, stroke, heart disease,
and lung cancer.
• Be a good role model for her child.
• Have fewer wrinkles.
• Have clothes, a car, a home, and
breath that smell better.
• Save money that can be spent on
other things.
• Enjoy the smell and taste of food
again.
• Feel great about quitting.
Sample Contents:
Potential Cost Savings
43
Summary of Tasks for TIPS
Program – cont.
Step 6. Contact TIPS Staff With Questions/Concerns
Tennessee Intervention for Pregnant Smokers
44
East Tennessee State University
Box 70621 Johnson City, TN 37614
Office: (423) 439- 6705 Fax: (423) 439-2440
Beth Bailey, Ph.D., Program Director: nordstro@etsu.edu
Laura K. Jones Cole, M.S., M.A., Program Coordinator: colelj@etsu.edu
TIPS Website: http://www.etsu.edu/tips
Resources
• American College of Obstetricians and
Gynecologists (www.acog.org)
• TIPS Online (www.etsu.edu/TIPS)
• Smoke-Free Families (www.smokefreefamilies.org)
• Treating Tobacco Use and Dependence
• Agency for Healthcare Research and Quality
(www.ahrq.gov)
1.
2.
45
Hegaard HK, Kjaergaard H, Moller LF, Wachmann H, Ottesen B. Multimodal intervention raises smoking cessation
rates during pregnancy. Acta Obstet Gynecol Scand, 2003;82:813-9.
Windsor RA, Woodby LL, Miller TM, Hardin JM, Crawford MA, DiClemente CC. Effectiveness of Agency for
Health Care Policy and Research clinical practice guidelines and patent education methods for pregnant smokers in
Medicaid maternity care. Am J Obstet Gynecol, 200;1:1.