April, 2014

While this training program was developed specifically for Tennessee, it may also be used by other states interested in implementing a similar prenatal smoking cessation model.
The S.M.A.R.T. Moms project staff welcome questions and inquiries from other states!

This training program is available online – with details provided later in this presentation on accessing the online materials - and may also be modified to be carried out as a live training.
Planning a Live Training?
Plan on FOUR HOURS to cover the agenda as outlined in this presentation.

• Welcome and Introductions
• Review of Training Objectives
• Why S.M.A.R.T. Moms?
• Overview of S.M.A.R.T. Moms
• Key Concepts in Smoking Cessation for Pregnant Women:
Risks of Smoking in Pregnancy
5 A’s and 5 R’s of Tobacco Cessation
Motivational Interviewing
Pharmacotherapy
• Implementation of S.M.A.R.T. Moms
• Questions and wrap-up

• To have a better understanding of the S.M.A.R.T. Moms program
• To recall the 5 A’s of the tobacco practice guidelines for counseling a patient who is ready to quit smoking
• To recall the 5 R’s of the tobacco practice guidelines for counseling a patient who does not want to quit smoking and to be able to effectively address roadblocks such as stress and weight gain
• To identify three techniques of motivational interviewing for counseling patients
• State the risk of smoking during pregnancy to the fetus
• State the risk of smoking during pregnancy on the infant/child post-delivery
• Understand the clinical trial data on pharmacotherapy for smoking cessation during pregnancy
• Verbalize process for counseling pregnant patients about using pharmacotherapy to aid in smoking cessation
• Be able to identify steps required to fully implement the S.M.A.R.T. Moms program with patients

• In 2012, 22.7% of all women in Tennessee smoked (BRFS)
• 17.1% of women in Tennessee smoked throughout pregnancy (CDC, 2011)
• In 2011, 13,486 babies were born to women who smoked (TDH, 2013)
• As many as 29% of pregnant WIC patients smoke in some regions of Tennessee
(TDH, Neonatal Summary Report , 2012)
• According to the Office of the Surgeon General, smoking is THE most important modifiable cause of poor health for women, noting specifically poor pregnancy outcomes and poor reproductive health.

As a health care provider, you can make a tremendous impact on your patients’ health.
“A brief cessation counseling session of 5-15 minutes, when delivered by a trained provider with the provision of pregnancy specific, self help materials significantly increases rates of cessation among pregnant smokers.”
(Tobacco Control 2000; Vol. 9,Suppl 3:iii80-iii84,September 2000, BMJ Publishing Group
Ltd.)

• Originally implemented in Tennessee from 2002 to 2006 as part of a grant from the
March of Dimes, and administered through MTSU’s Center for Health and Human
Services, with the TN Dept. of Health (TDH) as a project partner
• Primarily implemented in WIC clinics, though also with private providers
• The grant became self-sustaining and continues to date, most recently in 2013 being cited by TDH as a “Rising Star” Effective Practices program for Tennessee counties receiving Tobacco Settlement dollars.
• During the initial grant period, the S.M.A.R.T. Moms project trained providers in best practices smoking-cessation techniques for pregnant women, allowing them to counsel over 13,000 women between 2002 and 2006 when the project was fully funded.

• A toolkit has been developed to assist other states and organizations in developing similar programs and to orient providers in TN new to the program with how it may be implemented.
• S.M.A.R.T. Moms is based on the “5 A’s” approach to smoking cessation—Asking, Assessing, Advising, Assisting, and Arranging— which is an evidence-based method that is used in many programs.
• The 5 A’s described in the kit and included in the training are taken from “Treating
Tobacco Use and Dependence: A Clinical Practice Guideline,” produced by the U.S.
Public Health Service.

• Key components of the program are:
Tool Kit
Training
• Tobacco Consultation Record
Patient Self-Help Guide
Tennessee Tobacco Quitline Resources

• At the end of the funded grant period for the pilot project, over 13,000 pregnant women had been counseled by trained providers using “best practices,” 5 A’sbased counseling since the inception of the project in 2002.
• Approximately 77 percent of women who received the self-help guide and counseling agreed to attempt smoking cessation.
• Statewide, 24.4 percent of those who received counseling AND the cessation guide AND for whom smoking cessation data was available, quit smoking.
• Statewide, 21.4 percent of those who did not receive the guide but were counseled AND who had complete data records on smoking cessation quit smoking.

•
• Risks of Smoking in Pregnancy
• 5 A’s and 5 R’s of Tobacco Cessation
• Motivational Interviewing
• Pharmacotherapy
Online provider training for prenatal smoking cessation provided though Joan C. Edwards School of Medicine at Marshall
University
For those who are participating in a live training session, the session will include viewing the web-based training to address these topics.

•
Online provider training:
• Features Dr. Lynne Goebel, MD, Internal Medicine, and Dr.
Brenda Mitchell, MD, OB/GYN
• Includes printable materials, certificate of completion for providers
• Patient scenarios and interactive activities as part of the training
• Visit Marshall University’s Website at
• http://www.musom.marshall.edu/medctr/med/tobaccocessati on/pregnancyandsmoking/login.aspx

NOTE TO ONLINE TRAINING PARTICIPANTS:
•
Before completing this PowerPoint presentation, please click on the link below or cut and paste in your browser and follow the instructions to complete the online training.
http://www.musom.marshall.edu/medctr/med/tobaccocessation/pregnancyandsmoking
/login.aspx
After completing the online training, please return to this presentation to view the remainder of this presentation.

• Tobacco Cessation Guidelines:
• 5 A’s – Ask, Advise, Assess, Assist, Arrange
• 5 R’s – Relevance, Risks, Rewards, Roadblocks, Repetition
Motivational Interviewing:
• Decision Analysis – “Good” or “Bad” about staying the same, and about changing
• OARS – Open-ended questions, Affirm, Reflect, Summarize
• Ready, Important, Successful

• Pharmacotherapy
• Weigh risks of medication against benefit of not smoking
• No large randomized control trials to confirm safety
• More like to be necessary for heavy smokers – i.e., those smoking more than 1 pack per day
• Behavioral Intervention “Cold-Turkey” is first line treatment

•
Before completing this PowerPoint Presentation, please click on the link below or cut and paste in your browser and download a copy of the
S.M.A.R.T. Moms tool kit for review.
http://www.mtsu.edu/achcs/current_projects.php
After reviewing the toolkit, please return to this presentation to complete the training session.

•
Easy Implementation Steps:
• Participate in training (online or live training session) and review materials including the toolkit.
• Train other staff working with prenatal women.
• Provide multiple copies of “Tobacco Consultation Record,” the
5 A’s-based patient self-help guide, and other patient education materials on smoking and tobacco to staff working directly with pregnant women.
• Begin counseling patients using techniques learned through the online learning modules.
• Share patient education materials and resources, including information on the Tennessee Tobacco Quitline.
• Collect all completed Tobacco Consultation Records and give to director who will submit to S.M.A.R.T. Moms staff on a quarterly basis.

•
Tobacco Consultation Record Form
NOTE that EVERY pregnant smoker will have a completed consultation form, including postpartum data.
ONLY women indicating a commitment to quit smoking will receive the cessation guide, but EVERY pregnant smoker will have the completed form with postpartum data.

Tobacco
Consultation

•
More on the Tobacco Consultation Record:
• The Tobacco Consultation Record should be completed for each patient that smokes – regardless of her intent to quit.
• Form is kept in the patient’s records until the postpartum visit is completed.
• Forms are collected by director and submitted to S.M.A.R.T.
Moms project staff quarterly.
• All information is kept confidential and there is no identifying patient information.
• Study ID will be filled in if that information is needed; if there is nothing in this line, please leave it blank.

•
• ALL prenatal patients that currently smoke are eligible for this smoking cessation intervention.

Dr. Jo Edwards martha.edwards@mtsu.edu
615-898-2905
Cynthia Chafin cynthia.chafin@mtsu.edu
615-898-5493
Caron Petersen caron.petersen@mtsu.edu
615-494-8986

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• For those participating in a live training, this is the portion of the agenda where post-tests, evaluations, and CEUs/CMEs will be addressed.