Best Practice Interventions
Jolie Person
Texas Department of State Health Services
Learner Centered Objectives

 Participants will describe the adverse effects of
smoking on the mother, her unborn child, and
family.
 Participants will discuss the effectiveness of prenatal
smoking cessation interventions.
 Participants will compare three Best Practice
interventions for smoking cessation.
Community Health Worker Continuing Education Unit: 1
Competency: 0.5 Knowledge, 0.5 Communication
Video Clip - 25 Ways to Quit Smoking. Bill Plimpton
Prevalence of Tobacco Use

 Approximately 13% of women reported smoking
during the last 3 months of pregnancy.
 Of women who smoked 3 months before
pregnancy, 45% quit during pregnancy.
 Among women who quit smoking during
pregnancy, 50% relapsed within 6 months after
delivery.
Pregnancy Risk Assessment Monitoring System (PRAMS)
Predictors of
Smoking During Pregnancy

 A Smoking Partner
 A Large Number Of Children
 A High Rate Of Tobacco Consumption
 Deficiencies In Prenatal Care
Schneider, S., Huy C., Schutz J., & Diehl, K. (2010). Smoking cessation during pregnancy: a
systematic literature review. Drug Alcohol Rev, 29.
Tobacco 101

 Tobacco is a plant whose brown-colored leaves are
cured and dried. Tobacco may also be classified as a
drug.
 By definition, a drug is a nonfood substance that can
cause changes in the function of the body and/or
mind.
Types of Tobacco
Cancer-Causing Chemicals
Formaldehyde: Used to embalm dead bodies
Benzene: Found in gasoline
Polonium 210: Radioactive and very toxic
Vinyl chloride: Used to make pipes
Toxic Metals
Chromium: Used to make steel
Arsenic: Used in pesticides
Lead: Once used in paint
Cadmium: Used to make batteries
Poison Gases
Carbon monoxide: Found in car exhausts
Hydrogen cyanide: Used in chemical weapons
Ammonia: Used in household cleaners
Butane: Used in lighter fluid
Toluene: Found in paint thinners
There are over 4,000 chemicals in
tobacco smoke
599 Additives
At least 69 of those 4,000
chemicals are known to cause
cancer
Secondhand Smoke
Mainstream Smoke
(smokers inhale
about 15% of the
smoke from a
cigarette)
Sidestream Smoke
(smoke from the
burning end of the
cigarette)
Responsible for 3,000 lung cancer deaths in non-smokers each year
(Source: American Cancer Society)
Smokeless Tobacco

 Not a safe substitute for cigarettes
 Increases the risk for oral cancer and other health
problems
 Contains nicotine, the same addictive drug found in
cigarettes.
Adverse Effects of Tobacco Use
 Frequent colds
 Emphysema
 Smoker’s Cough
 Heart Disease
 Gastric Ulcers
 Stroke
 Chronic Bronchitis
 Cancer
 Increase in heart rate
and blood pressure
 Premature aging
 Hardening of the
arteries
 Gum disease, recession
 Delayed wound healing
 Risk of developing
Type 2 diabetes is 2-3x
higher
Adverse Effects of Tobacco Use
Video Clip - Smaller babies
http://www.youtube.com/watch?v=ypn3xpvA1eQ&feature=related
Adverse Effects of Tobacco Use
…on mom
 Difficulty getting pregnant
 Placenta separates from the womb too early, causing
bleeding
 Placenta covers the cervix, causing complications
 Water breaks too early
More studies needed: Possible adverse effect may
include pregnancy occurring outside of the womb
Centers for Disease Control
Adverse Effects of Tobacco Use
…on family members
Children suffer from bronchitis, pneumonia,
hyperactivity, middle ear infections, upper respiratory
infections and are frequently hospitalized.
Teens are more likely to become
smokers when a parent smokes.
As a result, they will suffer
greater long-term health effects
such as cancer, heart disease and
progressive lung disease like
emphysema.
Adverse Effects of Tobacco Use
…on the unborn baby
Of particular concern are carbon monoxide, nicotine
and oxidizing chemicals.
Nicotine may cause constrictions in the blood vessels of
the umbilical cord, thereby decreasing the amount of
oxygen available to the fetus. This increases the risk of
complications such as:
 Miscarriage
 Premature birth
 Stillbirth
 Spontaneous abortion
Adverse Effects of Tobacco Use
…on the newborn
Babies born to mothers who smoke during pregnancy
have an increased risk of:
 Sudden Infant Death Syndrome (SIDS)
 Lower birth weight
 Mental retardation
 Brain dysfunction
 Respiratory infections
Facts about Quitting Smoking
 No matter what their age, most smokers want to quit
and most attempt to quit every year.
 Among current smokers, 70% report they want to
quit completely.
Interventions

a. Clinical Interventions
b. Five A’s
c. Brief Motivational Interviewing
d. Pharmacotherapy
e. Quit Line / Telephone Counseling
Clinical Interventions
Recommendation: All patients should be asked if they
use tobacco and should have their tobacco use status
documented on a regular basis.
Evidence has shown that clinic screening systems, such
as expanding the vital signs to include tobacco use
status or the use of other reminder systems such as
chart stickers or computer prompts, significantly
increase rates of clinician intervention. (Strength of
Evidence = A)
Clinical Interventions
Recommendation: All physicians should strongly
advise every patient who smokes to quit because
evidence shows that physician advice to quit smoking
increases abstinence rates. (Strength of Evidence = A)
Clinical Interventions
Recommendation: Minimal interventions lasting less than 3 minutes
increase overall tobacco abstinence rates. Every tobacco user should be
offered at least a minimal intervention, whether or not he or she is referred
to an intensive intervention. (Strength of Evidence = A)
Recommendation: There is a strong dose-response relation between the
session length of person-to-person contact and successful treatment
outcomes. Intensive interventions are more effective than less intensive
interventions and should be used whenever possible. (Strength of
Evidence = A)
Recommendation: Person-to-person treatment delivered for four or more
sessions appears especially effective in increasing abstinence rates.
Therefore, if feasible, clinicians should strive to meet four or more times
with individuals quitting tobacco use. (Strength of Evidence = A)
Five A’s
1. ASK the patient about smoking status at the first
prenatal visit and follow-up with her at subsequent
visits.
a)
b)
c)
d)
e)
I have NEVER smoked or have smoked < 100 cigarettes in my
lifetime
I stopped smoking BEFORE I found out I was pregnant…
I stopped smoking AFTER I found out I was pregnant…
I smoke some now, but I have cut down…
I smoke regularly now, about the same as before…
If a-c, Reinforce her decision to quit (or never start), congratulate
her on quitting, encourage her to remain smoke free.
If d-e, Document smoking status and proceed to next four A’s.
Five A’s
2. ADVISE the patient who smokes to stop by
providing advice to quit with information about the
risks of continued smoking to the woman, fetus, and
newborn.
3. ASSESS the patient’s willingness to attempt to quit
smoking at the time. Quitting advice, assessment,
and motivational assistance should be offered at
subsequent prenatal care visits.
Five A’s
4. ASSIST the patient who is interested in quitting by
providing pregnancy-specific, self-help smoking
cessation materials.
Support the importance of having smoke free space at
home and seeking out a “quitting buddy,” such as a
former smoker or nonsmoker.
Encourage the patient to talk about the process of
quitting. Offer a direct referral to the smoker’s quit line
(1-800-QUIT NOW) to provide ongoing counseling and
support.
Five A’s
5. ARRANGE follow-up visits to track the progress of
the patient’s attempt to quit smoking. For current
and former smokers, smoking status should be
monitored and recorded throughout pregnancy,
providing opportunities to congratulate and
support success, reinforce steps taken towards
quitting and advise those still considering a
cessation attempt.
Modified from Treating Tobacco Use And Dependence: 2008 update.
Clinical Practice Guideline.
www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
Brief Motivational Interviewing
Recommendation: Motivational intervention techniques appear to
be effective in increasing a patient’s likelihood of making a future
quit attempt. Therefore, clinicians should use motivational
techniques to encourage smokers who are not currently willing to
quit to consider making a quit attempt in the future. (Strength of
Evidence = B)
Motivational interviewing is a technique whereby clinicians focus
on the patient’s desire to quit smoking, by developing an
awareness of the discordance between knowledge and behavior,
and then supporting patient’s self-efficacy in achieving that desire.
There are 4 principles of motivational interviewing:
Express empathy,
Develop discrepancy,
Roll with resistance, and
Support self-efficacy.
Pharmacotherapy
Nicotine Replacement Products
 Patch
 Gum
 Inhaler
 Nasal Spray
 Lozenge
Pharmaceuticals
 Bupropion (Zyban)
Pharmacotherapy
“The use of nicotine replacement products or other
pharmaceuticals for smoking cessation aids during
pregnancy and lactation have not been sufficiently
evaluated to determine their efficacy or safety.”
U.S. Preventive Services Task Force, 2009
Pharmacotherapy
“Pregnant smokers should be encouraged to attempt
cessation using educational and behavioral
interventions before using pharmacological
approaches. Treatment with nicotine replacement
therapy during pregnancy requires that the mother be
well informed about the potential risks vs. benefits.”
Benowitz, Dempsey Nicotine & Tobacco Research, February
2003
Pharmacotherapy
“The use of nicotine replacement therapy should be
undertaken with close supervision and after careful
consideration and discussion with the patient of the
known risks of continued smoking and the possible
risks of nicotine replacement therapy.”
The American College of Obstetricians and Gynecologists,
2010
Quit Line /
Telephone Counseling
Recommendation: Proactive telephone counseling,
group counseling, and individual counseling formats
are effective and should be used in smoking cessation
interventions. (Strength of Evidence = A)
Quit lines offer information, direct support, and
ongoing counseling, and have been very successful in
helping pregnant smokers quit and remain smoke free.
1-800-QUIT NOW
Best Practice
Tips for Quitting
http://www.youtube.com/watch?v=yWTRiI8NsQA&f
eature=related
http://www.youtube.com/watch?v=lf01Ti6bH8U
Tips for Quitting
If you smoke when you:
Try doing this:
Drink coffee
Have hot chocolate or herbal tea
Finish a meal
Get right up, take a walk, or go into another room
Watch TV
Do something else with your hands
(start a craft) and mouth (chew gum, eat a hard
candy)
Need to relax
Take a nonsmoking break or walk,
or take a break take a bubble bath, call a friend,
do your nails, ask a friend to babysit for 30 minutes,
even if you stay home
Tips for Quitting
It also helps to keep your hands and mouth busy.
Your hands:
Your mouth:
Knit or sew
Chew gum
Play with a rubber band
Eat some fresh fruit
Hold a pen or pencil
Use a straw or toothpick
Draw or doodle
Suck on hard candy
Squeeze a soft rubber ball
Try a cinnamon stick
Work on a craft project
Sip water or juice
Decorate your baby’s room
Have a frozen fruit bar
Massage your fingers or hands
Have some popcorn
Resources
www.dshs.state.tx.us/tobacco
Resources
BecomeAnEX.org
Great tools to help
people quit
Online Quit Plan
Resources
www.cdc.gov/tobacco
Resources
Smokefree.gov or espanol.smokefree.gov
Resources
Information for Smokers and Their Families
1-800-QUIT-NOW -- (1-800-784-8669); TTY 1-800-332-8615. Provides
support in quitting, including free quit coaching, a free quit plan, free
educational materials, and referrals to local resources.
Smokefree Women -- Provides information and resources on quitting
smoking targeted at pregnant and non-pregnant women.
Smokefree.gov -- Provides general resources for smokers to quit
Become an EX: For pregnant and postpartum smokers -- A quit
smoking program developed by the American Legacy Foundation.
Stay Away from Tobacco -- Smoking cessation resources for patients
and providers.
The March of Dimes -- Quitting tips for pregnant smokers.
Smoke-free homes and cars program -- Provides materials and
resources for protecting children from secondhand smoke developed
by the Environmental Protection Agency..
Information for Health Care Professionals
American College of Obstetricians and Gynecologists: Smoking
Cessation -- Smoking cessation resources for patients and providers
Centers for Disease Control and Prevention, Division of Reproductive
Health -- Highlight of data on tobacco use during pregnancy and
resources.
Office of the Surgeon General: Tobacco Cessation Guideline Clinical
Practice Guidelines, Treating Tobacco Use and Dependence, is available
here. The guideline was designed to assist clinicians; smoking cessation
specialists; and health care administrators, insurers, and purchasers in
identifying and assessing tobacco users and in delivering effective
tobacco dependence interventions. This site also has clinician resources
such as a Quick Reference Guide, tear sheets for primary and prenatal
care providers, and consumer materials.
Quick Reference Guide for Clinicians. Treating Tobacco Use and
Dependence. (PDF) --This reference guide contains strategies and
recommendations from the Public Health Service-sponsored Clinical
Practice Guideline, Treating Tobacco Use and Dependence. (requires
Adobe Reader)
Information for Health Care Professionals
Smoke-Free Families -- Resources to help counselors of pregnant
women who smoke, includes clinician resources, technical assistance
tools, and patient materials.
The Smoking Cessation and Reduction in Pregnancy Treatment
(SCRIPT) Program -- An evidence-based program that can be
implemented in offices to help pregnant women quit smoking.
Treatobacco.net -- Presents evidence-based information about the
treatment of tobacco dependence.
Information for Health Care Professionals
American Academy of Pediatrics (AAP) -- Provides tools and resources
to help clinicians and communities, and supports research and policy
development to create a healthy environment for children, adolescents,
and families. Also includes the AAP Policy Statement of tobacco use as
a pediatric disease.
How Tobacco Smoke Causes Disease: What It Means to You -- An easyto-read booklet explaining new scientific findings about how deadly
cigarettes are and how quickly they can damage your body.
Infant Risk Center -- Provides up-to-date evidence-based information
on the use of medications during pregnancy and breastfeeding.
Key Messages for Promoting
Smoking Cessation
 Question and document tobacco use at every visit.
 Understand the challenge to quit and expect relapse.
 Identify readiness to quit to best tailor approach to
patient.
 Treatment is effective and multiple options allow for
individualized interventions.
Thank you!
Jolie Person
Maternal and Child Health Program
Texas Department of State Health Services
Health Service Region 1 - Canyon, Texas
jolie.person@dshs.state.tx.us
806-655-7151