BPS22-B
AMCHP Best Practice Submission-2008
BACKGROUND
1. Name of your practice:
Missouri Model for Brief Smoking Cessation Training
2. Summary description:
Both cessation of tobacco use and prevention of relapse are key clinical
intervention strategies during pregnancy. A 5 to 15 minute counseling
session performed by appropriately trained health care providers has
been found to be effective with women who smoke. This evidence-based
intervention known as the 5 A’s is appropriate as a routine part of
healthcare with women of reproductive age and includes the following
five steps: Ask, Advise, Assess, Assist, and Arrange. Telephone quitlines
provide essential social support during tobacco cessation efforts. In the
Missouri Model for Smoking Cessation Missouri health care providers are
taught how to implement this intervention with their patients and are
advised how to access the Missouri Tobacco Quitline and to encourage
patients to use it. Using the quitline and its conveniently scheduled
telephone consultations with trained counselors, patients are helped to
deal with ambivalence, urges, triggers, relapses, and provided support.
3. Primary population focus:
Women's Health
4. Primary issue focus:
Workforce Development
5. Specific need or problem addressed (include supporting evidence):
Statistics indicate that 178,000 women in the United States die
prematurely from smoking related illnesses every year. Nationally, $75
billion is spent on smoking related health care costs for women and lost
productivity each year. The unique risks for women of reproductive age
who smoke include: 1) decreased fertility; 2) increased risk of stroke and
other serious side effects if taking birth control pills; 3) decreased
effectiveness of the pill; 4) if pregnant, increased rate of premature
delivery; and 5) increased risk of low-birth weight babies.
Despite these well-documented health effects of smoking during
pregnancy, 18.1% of Missouri women smoked during pregnancy in 2004
ranking Missouri 8th in the nation. Provisional data from the Missouri
Pregnancy Related Assessment and Monitoring System (MoPRA – a
pilot PRAMS project) indicates that 17.7% of women smoked during the
last 3 months of pregnancy. Smoking rates among pregnant women and
women of childbearing age have been consistently higher in Missouri
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than the rest of the nation. Sixteen point five percent of Missouri women
with early prenatal care (first trimester) smoked during pregnancy.
Because pregnancy is considered as a defining moment in a woman’s
life, prenatal care providers should view this as an opportunity to
encourage pregnant women to quit smoking.
Smoking during pregnancy is the single most preventable cause of
illness and death among mothers and infants and thus is one of the most
important modifiable causes of poor pregnancy outcomes.
6. Overall goal and key objectives:
The Missouri Model addresses Missouri smoking statistics through
ultimately reducing tobacco use in women of reproductive age,
particularly pregnant women.
· Health care providers will be provided smoking cessation skills for
interventions with women of reproductive age.
· Health care providers trained will indicate confidence in using the 5 A’s
to help women of reproductive age quit smoking as determined through
evaluation tool analysis.
· Referrals to the Missouri Tobacco Quitline will increase determined
through the 3 month surveys and Quitline reports
DESIGN
7. Theoretical foundation and/or science-base (e.g., teen pregnancy
program based on Kirby's 10 Antecedents of Teen Pregnancy):
The Missouri Model is based on the evidence-based U.S. Public Health
Services’ five-step intervention (5 A’s) and adopted by the American
College of Obstetricians and Gynecologists (ACOG) in 2002. Developed
and presented by faculty associated with the University of Missouri in
Columbia (UMC), the Missouri Model, in addition to the 5 A’s,
incorporates the transtheoretical model on stages of change,
motivational interviewing, and referrals to the Missouri Tobacco Quitline
for intervention and support.
8. Guidelines, protocols, models or standards used in your practice (e.g.,
community-based health center using Bright Futures guidelines to
conduct well-child screenings):
Both cessation of tobacco use and prevention of relapse are key clinical
intervention strategies during pregnancy. A 5 to 15 minute counseling
session performed by appropriately trained health care providers has
been found to be effective with women who smoke. This evidence-based
intervention known as the 5 A’s is appropriate as a routine part of
healthcare with women of reproductive age and includes the following
five steps: Ask, Advise, Assess, Assist, and Arrange. Telephone quitlines
provide essential social support during tobacco cessation efforts.
9. Quality improvement process (i.e., to incorporate peer/stakeholder
input and review, lessons learned):
The quality improvement and evaluation processes were combined into one tool for the one- hour
trainings and collected information on the following:
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General demographics and current smoking status of the trainee;
Length of experience in smoking cessation with clients;
Familiarity with the U.S. Public Health Services’ Clinical Practice Guideline for Treating
Tobacco Use and Dependence;
Familiarity with the MO Tobacco Quitline;
Assessment of general knowledge regarding smoking in women;
Assessment of general knowledge regarding brief tobacco counseling;
Participant perceptions to: “The training provided me with confidence and skills to help
women quit smoking”;
Trainee perceptions to: “The 5 A’s could be realistically implemented in my routine
practice”; and
Effectiveness of the speaker and the presentation.
A follow-up survey was sent to all 2007 and 2008 training participants either two or three months after
the training to as certain changes in self-reported tobacco cessation skills and behaviors.
Pre- and post-training surveys, as well as three- month follow-up surveys, for the 2007 offerings showed
significant differences in knowledge and behavioral change in terms of smoking cessation discussions
with women and use of resources in smoking cessation interventions.
For the trainings that were conducted in 2007 participants reported a statistically significant
(p<0.05) improvement with respect to the knowledge, skills and attitudes / beliefs towards the use of
5A’s method for smoking cessation. Statistically significant improvements in perceived efficacy of the
5A’s approach (22% pre vs 73% post, p<0.01), confidence in using the 5A’s (18% pre vs 52% post, p<0.01)
and feasibility of practicing the 5A’s in routine clinical practice (37% pre vs 71% post, p<0.01) were
observed. At the three month follow up survey 88% of the respondents expressed confidence in their
ability to implement the 5A’s and a self-reported increase in referrals to the Missouri Tobacco Quitline
(34% pre-training vs 77% at three month follow up, p<0.01).
The trainings in 2008 were of 60-90 minutes in durations and were targeted towards specialized
health care professions such as dentists, respiratory therapists, and other allied health professions. 85%
of the respondents either agreed or strongly agreed that brief interventions using the 5A’s is an effective
way to help women quit smoking and 81% of the respondents felt that the training provided them with
confidence and skills to help women of reproductive age quit smoking. 77% of the respondents felt that
the 5A’s could be implemented in routine clinical practice. It is also note worthy that prior to the
training 80% of participants were unaware of the Missouri Tobacco Quitline – a valuable resource for
women trying to quit smoking.
In summary, the Missouri Model for Brief Smoking Cessation Intervention training in 2007 and
2008 could be deemed as an effective program to enhance smoking cessation efforts on a statewide
basis.
10. Evaluation methods (i.e., desired process and outcome measures,
techniques, data sources):
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The outcomes evaluation involved a pre-training survey that was
administered at the onset of each session to collect general
demographics (i.e. sex, age range, race/ethnicity, length of experience in
smoking cessation with clients, familiarity with A Clinical Practice
Guideline for Treating Tobacco Use and Dependence, and current
smoking status of participant, as well as general knowledge regarding
smoking in women and brief tobacco counseling skills. A post-training
survey measured the same knowledge at the end of the session. A three month
follow-up survey was developed and mailed to all participants to
ascertain changes in self-reported tobacco cessation skills and behaviors
11. Relevant MCH block grant measures:
Yes
Yes, decreasing perinatal mortality, decreasing the number of preterm
births, decreasing the number of low birth weight babies, and decreasing
smoking among women of reproductive age.
IMPLEMENTATION
12. Timeframe (implementation to completion or ongoing):
The Missouri Model for Smoking Cessation was developed through a
contract with the University of Missouri-Columbia in 2005. From May to
September 2006 training sessions were provided targeting health care
providers working with women of reproductive age at no charge at eight
locations across the state.
13. Resources utilized (i.e., type/amount of personnel, funds,
supplies/materials, etc):
$20,000 for the development of the program and $20,000 for the training.
14. Collaboration (i.e., type and extent of partner/stakeholder
involvement):
The project has collaborated with state and local organizations to alert
interested health care providers and entities and maximize the reach of
available training, while avoiding duplication of services. Outreach
included use of the Missouri Department of Health and Senior Services
(DHSS) electronic notification network to local public health agencies, as
well as contacts within the Federally Qualified Health Care Centers,
substance abuse treatment centers, managed care entities, Perinatal
Substance Abuse Committees within the metropolitan areas, and
applicable advisory groups within DHSS. Contacts with the Missouri
Section ACOG; the Missouri State Medical Association; the Missouri
Association of Osteopathic Physicians and Surgeons; the Missouri
Hospital Association; the Missouri Departments of Mental Health, Social
Services, Corrections, and Health and Senior Services; the University of
Missouri-Columbia; the Missouri Chapter MOD; the Missouri Chapter
American Academy of Pediatrics; the Missouri Association of Family
Physicians; Title X providers and others was also utilized.
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15. Implementation assets/opportunities:
Working with multiple types of healthcare providers to educate them
using this model.
16. Implementation challenges:
Engaging physicians in the training process and providing training at a
time or venue that is convenient for them.
Other Challenges
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A lot of advance planning and effort were required to bring people to a face -to- face training
session. Even with confirmed reservations, some trainings had far fewer attendees than
projected.
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Research and information regarding tobacco cessation, pharmacotherapy, and evidence-based
or promising strategies are continually evolving. Presenters need to keep their knowledge level
current and to keep all their program materials current as well.
OUTCOMES
17. Key accomplishments:
Provided the Missouri Model for Brief Smoking Cessation training to healthcare
providers who had not previously been educated in the model or the 5’s.
Highlights of the Missouri Model Training Program Include:
 Interactive learning using proven strategies to increase the percentage of patients who
will stop smoking.
 Information and techniques on how to integrate these strategies into the clinical setting.
 Receipt of a comprehensive manual (including a CD to use for training of other office
personnel) and other useful resources for the clinical setting.
18. Evidence (quantitative or qualitative) of positive outcomes achieved
by your practice:
Yes
Coordinated evidence-based interventions including the 5 A’s,
transtheoretical model on stages of change, motivational interviewing,
and referrals to the Missouri Tobacco Quitline for intervention and support.
19. Expert/peer review process that determined your practice to have
significant evidence of effectiveness:
No
20. Evidence (e.g., through use of control group, etc) demonstrates that
outcomes were achieved by your practice and not due to outside factors:
No
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21. Practice has been replicated (e.g., other settings, populations):
No
22. Key lessons learned (positive and negative):
 MO Model 2008 was successful in transcending discipline and practice modalities. Specifically,
the 5 A’s concepts and Motivational Interviewing techniques, as well as the Missouri Tobacco
Quitline and other resources, were applicable with various providers.
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There was considerable interest among the disciplines regarding the Motivational Interviewing
approach as a counseling technique to address various clients who wished to change their
behaviors.
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The American College of Obstetricians and Gynecologists (ACOG) contributed important support
to the MO Model efforts. ACOG waived the customary $20 fee for three Continuing Medical
Education (CME) units to individuals of any discipline who attended the trainings, successfully
completed an ACOG quiz/evaluation tool, and whose licensing body would accept the CME
credits. The ACOG CMEs served as an incentive for the physicians to attend the trainings. All
successfully passed the ACOG quiz.
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In addition to the availability of the ACOG CMEs, dentists, respiratory therapists, and dental
hygienists attending the MO Model training were able to receive discipline-specific CEUs at no
charge. The CMEs served as an incentive for participation and were paid for and distributed by
the host organizations.
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There are multiple costs involved in training for everyone involved. Participants and trainers
leaving work and traveling to other locations are expensive. A webinar presentation is an option
that might be more cost-effective.
FOLLOWUP
23. Sustainability plan in place/known next steps:
Yes
It is critical to network with physicians and thus the decision was made to
develop an “executive summary” of the Missouri Model in the 2007
project proposal to provide one-hour “executive summary” Missouri
Model trainings to physicians at medical meetings at four state locations.
The 2007 project will build on the success of the 2006 Missouri Model
with its training components and evaluation methodologies and providing
additional healthcare provider trainings, while addressing the need for
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increased physician participation through the “Executive Summaries”. The epidemiologist is
analyzing MO model data from 2008. These data will be combined with 2007 data and the
findings will be shared externally shortly thereafter.
24. Available products/resources (e.g., website, published article, agency
report, brochures, online toolkit, etc):
Yes
Missouri Model on Smoking Cessation Training Manual Clinical Practice
Guidelines from the Agency for Healthcare Research Women Who
Smoke” charts Smoking Cessation for Pregnancy and Beyond CDs
ACOG Guide to Helping Women Quit Smoking Missouri Quitline
materials
25. Anything else you'd like to share about your practice that is important
for others to know:
No
26. Person to contact for more information:
Information withheld for the purposes of review
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