Smoking Cessation and Perinatal Issues

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Smoking Cessationand Perinatal Issues

• Scott McIntosh, PhD
• University of Rochester
• School of Medicine and Dentistry
• Department of Community and Preventive Medicine
• 585.273.3876
• scott_mcintosh_at_urmc.rochester.edu

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I. Stages of Change Model (The Transtheoretical
Model)

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse / Recycle

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Background of Theory

• Prochaska, James (1979) Systems of
  Psychotherapy A Transtheoretical Analysis
• There were too many theories in the field of
  psychotherapy
• Comparative analysis of 18 major theories of
  psychotherapy and behavioral change
• Consciousness raising (Freudian / Psychodynamic)
• Contingency management (Skinnerian / Behavioral)
• Helping relationships (Rogerian / Client
  Centered).
• Thus, the term transtheoretical.

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PRECONTEMPLATION

• Has no intention to take action within the next 6
  months
• Counseling in this stage may decrease chances of
  making a decision to change their behavior.
• Smokers who are "in denial" may not see that
  the advice applies to them personally. Patients
  with high cholesterol levels may feel "immune" to
  the health problems that strike others. Obese
  patients may have tried unsuccessfully so many
  times to lose weight that they have simply given
  up.

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CONTEMPLATION

• Intends to take action within the next 6 months
• During this stage, patients are ambivalent about
  changing. Giving up an enjoyed behavior causes
  them to feel a sense of loss despite the
  perceived gain. During this stage, patients
  assess barriers (e.g., time, expense, hassle,
  fear, "I know I need to, doc, but ...") as well
  as the benefits of change.

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PREPARATION

• Intends to take action within the next 30 days
  and has taken some behavioral steps.
• Patients prepare for a specific change. They
  may experiment with small changes as their
  determination increases sampling low-fat foods
  may be an experimentation with or a move toward
  greater dietary modification. Switching to a
  different brand of cigarettes or decreasing their
  drinking signals that they have decided a change
  is needed.

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ACTION

• Has changed overt behavior for less than 6
  months.
• Failed New Year's resolutions provide evidence
  that if the prior stages have been glossed over,
  action itself is often not enough. Any action
  taken by patients should be praised because it
  demonstrates the desire for lifestyle change.

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MAINTENANCE

• Has changed overt behavior for more than 6
  months.
• Maintenance and relapse prevention involve
  incorporating the new behavior "over the long
  haul."

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RELAPSE / RECYCLE

• A relapse is not seen as a failure, but as
  reverting to an earlier stage, such as
  Contemplation.
• Discouragement over occasional "slips" may halt
  the change process and result in the patient
  giving up. However, most patients find themselves
  "recycling" through the stages of change several
  times before the change becomes truly
  established.

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The 5-A Model for Health Care Provider
Intervention

• At all patient/client contacts
• Ask whether patient smokes (or exercises, or
  eats a healthy diet)
• Advise them to stop smoking (or begin regular
  exercise or begin a healthy diet)
• Assess whether patient wants to take action
• Assist patient in developing plan
• Arrange follow-up

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ASK
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Promoting Motivation to Quit for Patients Not
Ready for Action

• The Four Rs
• Relevance
• Risks - short- and long-term
• Rewards
• Repetition

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Help Develop a Quit Plan

• Set a quit date, preferably within 2 weeks
• Inform family/friends/coworkers of the decision
  and request understanding
• Remove cigarettes from the environment and avoid
  smoking in usual locations (e.g., home, car)
• Review previous quit attempts, factors associated
  with relapse, successful coping strategies
• Anticipate challenges to quitting (e.g.,
  withdrawal)

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• New Behaviors/Problem Solving/Skill Training
• Identify high risk situations for relapse
• Identify and practice coping strategies

• Support
• Encourage the patient/client
• Note that effective treatments are available
• Note that half of all people who ever smoked have
  quit
• Communicate your belief in your client
• Communicate caring and concern
• Ask how client feels about quitting
• Directly express caring
• Be open to clients fears of quitting

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Support (contd)

• Encourage the patient to talk about the quitting
  process
• Reasons for quitting
• Problems encountered when quitting
• Successes
• Concerns/worries
• Provide basic information about quitting (e.g.,
  nicotine withdrawal/recovery, most people quit
  several times, even a puff can lead to relapse)

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Relapse Interventions

• Long-term follow-up can help prevent relapse
• Reframe relapse as learning opportunity. Focus
  on success during cessation.

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Offer a Range of Options

• Clinics - on site
• By specialists or others
• Follow-up by specialists
• Individual counseling sessions
• Telephone counseling/hotline
• By specialists
• 1-800-4CANCER
• Self-help materials
• Specialist-assisted

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Local Studies of Interventions with Quitlines
and Websites

• New York State Department of Health Grants
• New York State Quitline
• New York State Tobacco Cessation Centers

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Smoking during pregnancy is a major risk factor
for pregnancy related illness and death, and has
been linked to

• 30 - 70 increase of miscarriage
• 20 - 30 risk of still birth
• 30 increase in perinatal mortality
• 80 increased risk of placenta praevia for
  16-20/day
• smokers
• 20 increase in the risk of placental abruption
  for every ½
• packet smoked

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Risk for the infant

• Smoking in pregnancy linked to
• Behavioral problems
• Respiratory problems
• The rate of infant mortality is 40 higher in
  smokers.
• Sudden Infant Death Syndrome
• Babies born to smokers are up to 15 times more
  likely to die of cot death (risk increases with
  the number of cigarettes smoked)
• Even those who smoke between 1 and 9 cigarettes a
  day, the risk to their babies is 5 times greater
  than non-smokers.

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• However although well documented that smoking
  in pregnancy is harmful, 30 of women who smoke
  continue to smoke during pregnancy (HEA 99)

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The scale of the task

• Pregnant women were not accessing the main
  stream service
• Heath professionals lack of enthusiasm/empathy
  and poor
• referral rates
• Reluctance of Consultants /GP,s to prescribe NRT
  during
• pregnancy due to current licensing, despite
  the fact that it
• has been shown in general research trials to
  double an
• individuals chance of quitting
• Difficulty obtaining accurate data on smoking
  during
• pregnancy to assist us in targeting our
  interventions

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Barriers to uptake of smoking cessation services
by pregnant women in Sunderland with
corresponding element of intervention to overcome
them
Findings
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What is it like being a pregnant smoker?

I feel got at and victimised. I think its
wrong and I would be better not smoking but its
not so easy now that Im pregnant myself I wish
I could give up but like everyone says its not
easy at all to do. When Im out I feel as
though people, the public in general are thinking
bad things. They might be thinking I could be
jeopardising the babys future and they might
think Im very selfish. I thought the same when
my friend was pregnant years ago I thought she
shouldnt be smoking
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Marketing Materials

• I had some leaflets from the midwife. Wasnt up
  to much, told me what I already knew. About
  risks to the baby. Tell me something I dont
  already know, tell me something new I can try.
• Any informational materials need to be focused
  on solutions
• to giving up rather than the risks to their
  unborn child. Such
• solutions might include how to deal with
  cravings, how to
• cope with anxieties about weight gain, or how
  to cope with
• mood swings. The women were dissatisfied with
  existing
• materials.

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Difficulty accessing nicotine replacement

• Many Consultants/GP,s were worried/reluctant to
  prescribe
• NRT products were (until very recently)
  contraindicated
• during pregnancy/breast feeding

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National Institute of Clinical Excellence
Guidance (march 2002)

• The use of NRT in pregnant and breast feeding
  mothers who
• could not quit without a cessation aid, could
  be considered
• following a R/B analysis by a health
  professional who should
• take into account
• the significant harm associated with continuing
  to smoke and
• that it can be expected that NRT will deliver
  less nicotine (and
• none of the other potentially disease-causing
  agents) that
• would be obtained from cigarettes. (Para 3.2)

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Aims

• To update Health Care Delivery professionals
  regarding the available research and current
  recommendations regarding the use of NRT during
  pregnancy/breast feeding
• Advise on current PHS guidelines
• Gain continued support

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• In a recent study (April 2002 June 2003)
• 541 pregnant women were referred to a
• specialized smoking cessation service
• following these principles
• 316 pregnant women set a quit date
• 131 pregnant women remain quit at their
  4 week follow up (short
  term abstinence)
• (42 quit rate)

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Tobacco Use is the 1 Public Health Problem

• Tobacco use is the single most avoidable cause of
  death and disability in our society
• Tobacco causes 430,000 deaths in the United
  States each year
• More than 1,100 people each day
• More than the total number of deaths from
  alcohol, suicide, homicide, illicit drugs,
  accidents, fires and AIDS -- COMBINED

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• If tobacco use were eliminated in the U.S.
• prevent 80-90 of all lung cancer and emphysema
• prevent 1/3 of all cancers
• prevent 1/4-1/3 of all cardiovascular diseases

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Smoking is an Addiction AND a Habit

• Although an addiction, Smoking has a BEHAVIORAL
  COMPONENT that must be recognized and changed.
• Learning new behavioral ways to cope with stress,
  to relax, etc. are all part of a successful plan
  of action.
• Smoking is the most important of the known
  modifiable risk factors for disease in the United
  States. (Former Surgeon General David Satcher)

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Psychosocial Effects

• Habit
• With 10 puffs/per cigarette a pack-a-day smoker
  (20 cigarettes per day) gets
• 200 hits of nicotine per day
• 1,400 hits each week, and
• 73,000 hits each year
• Double these numbers for a 2-Pack-A-Day smoker
• A deeply ingrained habit
• Each puff is associated with an environmental or
  emotional event that becomes a cue to smoke

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Effective pharmacotherapies should be used with
all patients trying to quit.

• First line medications
• OTC
• Nicotine Gum
• Nicotine Patch
• Nicotine Lozenge
• PRESCRIPTION
• Nicotine Inhaler
• Nicotine Nasal Spray
• Bupropion SR

• Second line meds
• PRESCRIPTION (Off Label only)
• Clonidine
• Nortriptyline

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Nicotine Replacement Therapy Maintain addiction
while breaking the habit
Blood Nicotine Levels Red Cigarette Green
Average Daily Level Blue Nicotine Replacement
Therapy (NRT)
(Withdrawal Symptoms)
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Nicotine Gum, Patch, Lozenges, Zyban

• Gum Long Term Abstinence 24 (Vs. 17 Placebo)
• Patch Long Term Abstinence 31 (Vs. 14
  Placebo)
• Zyban Non-nicotine medication shown to be
  effective (31 Abstinence vs. 17 Placebo)

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NEED 3 THINGS TO STOP SMOKING

• The 3 most important factors that predict a
  successful Quit Attempt
• Social Support (e.g., Family/Friends, Classes,
  Phone Support, Changing Society)
• New Behaviors (e.g., Manuals, Behavior
  Modification, Relaxation, Dealing with Stress)
• Pharmacology (i.e., N.R.T. Zyban)
• Fiore et al. (2000)

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Ways to Become Smoke-Free

• Ways to Become Smoke-Free
• Clinics
• Health Care Provider Intervention
• Self-Help Interventions
• Clinically Proven Medications
• Patch and Gum and Lozenges (Over-The-Counter)
• Spray and Inhaler (Prescription)
• Zyban (a.k.a., Wellbutrin )
• 2nd Line Medications

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Self-Help Interventions

• Self-Help Methods can include
• Telephone Quitlines or Hotlines (Ossip-Klein
  McIntosh, 2003)
• Manual (Tailored may help)
• Pamphlets / Proactive Mailings
• Behavioral Programs
• Best (most effective) may be a combination of
  these

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Health Care Provider Interventions

• The length of counseling time and the variety of
  clinicians who counsel the patient have a direct
  impact on the number of patients that quit.
• Many different types of providers are effective
  in increasing smoking cessation rates (e.g.,
  physicians, nurses, dentists, psychologists,
  pharmacists, other cessation specialists)
• Combinations of two and three clinician types
  have greater influence on abstinence rates.
  (Fiore, et al., 2000).

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Primary Care Physicians

• Primary care physicians are logical intervention
  contacts for smokers of all ages.
• The average smoker visits a physician 4.3 times
  each year.
• There have been a wide range of reports of
  receipt of advice by physicians to stop smoking
  during this period -- from 42 to 70.7.
• This is improving, but many physicians still need
  training in specific interventions.

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Primary Care Physicians

• The effectiveness of health care provider
  interventions for smoking cessation has been
  demonstrated.
• Interventions can be incorporated into routine
  medical care.
• Interventions as brief as1-3 minutes have shown
  to be effective.
• Training in Guidelines has demonstrated
  improvements in guideline adherence.

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Physician Training

• In a current study, weve trained over 200
  providers (MDs, DOs, PAs, NPs) with a CME
  credit, face-to-face guideline-based course.
• Physicians are increasingly benefiting from
  instantaneous access to continuing education, as
  well as access to research, texts, online
  discussions, specialists, and patient data.
• The Internet is fast becoming a "clinical tool".

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GRATCC

• The goal of GRATCC (Greater Rochester Area
  Tobacco Cessation Center) is to train 13 clinical
  sites in Year 01 in Public Health Service
  guideline-based intervention and support for
  screening, treating, and referring patients for
  Nicotine Dependence.
• The 13 sites include Family Practices throughout
  the 5-County area, a Mental Health clinic, a
  chemical dependence Rehabilitation Clinic, and an
  OB/GYN practice. Clinicians (MDs, PAs, NPs)
  and all office staff will be trained on-site, and
  followed with ongoing support services and
  evaluation (Scott McIntosh, PhD, Deborah J.
  Ossip-Klein, PhD).

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GRATCC

• 10 to 15 clinical sites per year will be added in
  Years 02-05.
• GRATCC will provide
• an in-house intensive training for clinicians at
  least 2 times per year (Geof Williams, MD), and
• an intensive treatment option for 200 referred
  patients to a Rochester-based treatment program.
• Partners include ACS, ALA, AHA, Strong Health,
  BC/BS, Monroe Plan, and all local State-funded
  Tobacco Control initiatives, such as the County
  Action Coalitions and Reality Check for teens.
• In addition, all 5 county Departments of Health
  and the New York State Department of Health are
  partners, as is the New York State Quitline.

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GRATCC

• 2 of GRATCCs 13 sites are OB/GYN
• 1) Dr. Faig Morogos Sodus (rural)
• 2) Dr. Julius Avorkliyah West Main OB/GYN
• located in the inner-city area of Rochester
• connected to West Main Pediatrics (trained by us
  previously provider and office systems,
  technical support potential site for
  pediatrician interventions with parents at well
  visits)
• houses a Healthy Start Rochester project,
  supported by The Perinatal Network of Monroe

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GRATCC

• All three sites (OB/GYN, Pediatric, and "Healthy
  Start"), share the same office staff, offering
  unique opportunity to build infrastructure for 3
  "health care facilities (as defined by State
  Tobacco Control) training and technical support
  will be streamlined, and facilitate increased
  efficiency in the application of screening, 5A
  intervention by providers, and office systems
  maintenance and support.

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New York State Quitline

• Increased referral options beginning 2005
• Medicaid Uninsured
• Proactive Calls
• Free Nicotine Replacement
• Interactive Website (With Cessation in October,
  2004) nysmokefree.com
• Up to date referral to local cessation options
• 1-866-NY-QUITS

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THANK YOU!

• Scott McIntosh, PhD
• Department of Community and Preventive Medicine
• 585-273-3876
• scott_mcintosh_at_urmc.rochester.edu

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Point-of-care clinician opportunity
teachable moment
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Materials Design Targeted Materials

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Key Insights Physicians

• This is one of the most important things I can do
  for a patient who smokes
• I give brief counseling, but have never been
  formally trained to do so
• I find that guilt trips/ fear tactics are best
• Im willing to try a new approach
• If it is proven-effective, and not burdensome
• 3 hours of training isnt unreasonable
• ACOG endorsement is important to me
• I want to be involved, but my staff can be too

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Key Insights Nurses

• Id like to play a bigger role in helping
  patients quit smoking
• I cant do this on my own initiative, however
  the doctor must make a decision to involve me
• 3 hours of training? You must be joking.

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Message and Materials Design

• Focus on ways they can help
• Demonstrate cost-effectiveness
• Provide short, targeted training
• Show endorsement by major
• professional organizations,
• especially ACOG
• Acknowledge time constraints
• Provide tools that help providers
• Acknowledge that providers
• want to help but dont know how

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Quit lines offer effective treatment options for
pregnant smokers

• Media campaigns and clinician referrals work to
  encourage pregnant smokers to use quit line
  services
• State and national quit line services exist that
  are tailored to the needs of pregnant smokers
• Clinicians can use quit lines with confidence as
  an alternative to providing all counseling in
  their offices and clinics

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The National Partnership to Help Pregnant Smokers
Quit (http//www.helppregnantsmokersquit.org/)

• Over 40 national organizations have come together
  to form the Partnership
• An Action Plan has been developed to accomplish
  the dissemination goals
• Organizational agendas are lining up with the
  Action Plan
• A communications plan has been developed to
  support the Action Plan

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National Partnership Pledge

• We, the members of the National Partnership To
  Help Pregnant Smokers Quit, will work through
  health care providers, the media, worksites,
  communities, and states to deliver best-practice
  cessation programs, create supportive
  environments, and promote policies that can
  motivate and assist every pregnant smoker in her
  efforts to quit.

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National Partnership Guiding Principles

• 1. Our work is based on the best scientific
  evidence currently available on clinical and
  community strategies to increase tobacco-use
  cessation for pregnant women in the U.S.
• 2. To achieve change, we will work on multiple
  fronts, including clinical practice, media,
  policy, and community and social supports.
• 3. We will work to remove systems and other
  barriers to tobacco treatment for pregnant
  smokers.

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Using the Media Effectively

• to increase pregnant smokers knowledge of
  effective and accessible communication resources
  to help them quit
• to increase the number of pregnant smokers who
  utilize available quitline and other counseling
  services