Welcome To

1

• Welcome To
• Counseling
• For Prenatal Smoking Cessation
• In the Reproductive
• Health Care Setting
• Provided by Development Systems Inc. and the
  Missouri Department of Health

2
Additional Information Regarding the Smoking
Cessation Training Program

• The training manual and course was supported by
  Grant/Cooperative Agreement
• UT/CCU713702-05 from the Center for Disease
  Control and Prevention. Its contents are solely
  the responsibility of the authors and do not
  necessarily represent the official views of the
  Centers for Disease Control and Prevention.

3
Training Objectives

• Be able to explain how stopping smoking is one of
  the preventive measures likely to have a
  substantial impact on pregnancy outcomes.
• Be able to discuss how this pregnancy specific,
  material, can significantly increase rates of
  cessation among pregnant smokers.
• Be able to demonstrate smoking cessation
  counseling.

4
Topics To Be Covered In The Course

• History of prenatal smoking cessation courses and
  their effectiveness
• Statistics regarding smoking cessation and child
  and reproductive health
• General counseling information
• Theoretical basis for smoking cessation -
  transtheoretical model and its application
• Assessing an individuals dependence and need for
  counseling
• Smoking cessation counseling format
• Useful tools for providers
• Service provider office concerns
• Client resources -- immediate, local area,
  national level

5
Introductions

• Pair up with someone you dont know or dont know
  well. Get the following information about them
• Name
• Agency / Position Hold
• Why are they in the training what do they hope
  to gain.
• One thing that they want to share about
  themselves that doesnt deal with work (I.e.
  Family, Pets, Hobbies etc.).

6
Why Prenatal Smoking Cessation Counselingis
ImportantLegal Perspective
7
Reasons for Conducting Prenatal Smoking Cessation
Counseling

•      According to Missouri State Law
• All prenatal care providers must assess pregnant
  women for the risk and current use of alcohol,
  tobacco and other substances.
• All prenatal care providers must provide
  education regarding the effects of smoking on
  pregnant women and their fetus.
• Guidelines
• Refer to ACOG information

8
Additional Information To Take Into Consideration
Before Beginning Counseling
9
Cultural Competence Issues

• Characteristics of Cultural Competence Include
• An awareness of ones own cultural values, norms
  and beliefs
• An awareness and acceptance of the differences in
  cultural values, norms and beliefs
• Broad based knowledge of other cultures
• The ability to interact successfully in different
  cultural settings and with diverse cultural
  groups
• Knowledge of ones own limitations in interacting
  with individuals from other cultural backgrounds.

10
Historical Information on Smoking Cessation and
Womens Reproductive Health and Pregnancy Outcomes
11
Evidence-based Medicine
It has been estimated that only 4 of decisions
are based on strong evidence from clinical
research studies, 45 have no evidence from
research studies but moderate to strong consensus
among physicians, and 51 of decisions are based
on little evidence and consensus. Field and
Lohr, 1992
12
Prenatal Smoking Cessation Historical Information

• Incidence of low birth weight decreased due to
  smoking cessation.
• Prenatal smoking cessation interventions increase
  rates of smoking cessation during pregnancy.
• Am. Journal of Obstetric Gynecology, Vol. 1, 5,
  pg. 1328 1334
• Physician/nurse midwives are effective as change
  agents for smoking pregnant women.
• 15 minute one on one smoking cessation sessions
  accepted better by patients than most other
  methods of non-pharmaceutical cessation.
• Health Education Research Theory and Practice,
  Vol. 13, no. 3, pg. 413-438

13
Effects of Tobacco During Pregnancy

• Difficulty Conceiving
• Ectopic Tubal Pregnancies
• Poor Weight Gain
• Chronic Fetal Hypoxia
• Vaginal Bleeding
• Premature rupture of vaginal membranes
• Placenta Previa (2X)
• Abruptio Placentae (1.5X)
• Preterm Labor
• Spontaneous Abortion (20 Greater in smokers than
  non-smokers)

14
Effects on Newborns

• Premature Birth
• Intrauterine Growth Retardation
• Smaller Head Circumference
• Sudden Infant Death Syndrome (SIDS)
• Cleft Palate/Lip, Eye and Ear Malformations
• Hernias
• Congenital Heart Defects
• Central Nervous System Abnormalities
• Poor habituation to sound
• Changes in brain neurochemistry
• Tremors
• Behavior regulation problems

15
Effects on Growing Child

• More Respiratory Illnesses
• Diminished Lung Function
• Chronic Otitis Media
• Childhood Cancer
• Impaired Cognitive Abilities
• Diminished reading, verbal and math skills
• Lower IQ
• Poorer social skills and behavior regulation
  problems
• Changes in Brain Neurochemistry

16
Economic Impact of Smoking Pregnancy

• Overall costs related to smoking are between 135
  to 167 million
• Costs based on placenta previa, abruptio
  placenta, PPROM and pre-eclampsia associated with
  delivery.
• Smoking cessation interventions during pregnancy
  shown to decrease overall costs of pregnancy and
  care after delivery.
• American Journal of Preventive Med. Volume 15,
  num.. 3, pg. 212-218

17
CDC Smoking Prevalence Among Reproductive-aged
Women

• In 1965, 33 of all U.S. Women smoked.
• In 1992, 14.3 million aged 18-44 years were
  smokers (26.9).
• From 1987-1990, prevalence declined 3.7, from
  29.6 to 26.9.
• In Missouri, the overall rate of female smoking
  is 26 of women aged 18-44, 33 are smokers.

18
CDC Smoking Prevalence and Level of Education

• Prevalence inversely related to level of
  education.
• Highest rates among women with less than a high
  school education (40.2 in 1992, but down from
  46.5 in 1987).

19
Smoking Cessation During Pregnancy

• Stopping smoking is one of the few preventive
  measures likely to have a substantial impact on
  pregnancy outcomes.

20
Smoking Cessation During Pregnancy

• Pregnant smokers who stop smoking at any time up
  to the 30th week of gestation have infants with
  higher birth weight than women who smoke
  throughout their pregnancy.
• Pregnant women who stop smoking before the 16th
  week have infants with birth weights similar to
  those of babies whose mothers never smoked.

21
Smoking Cessation During Pregnancy

• Reductions in cigarette smoking documented by
  decrease in cotinineor other biologic markers, or
  by self report, have been associated with an
  increase in birth weight.

22
Smoking Cessation During Pregnancy

• Smoking cessation can also result in a permanent
  change in life-style that will reduce the risk of
  smoking-related chronic diseases.
• This life-style change can also be the framework
  on which other successful behavior changes can be
  based.

23
Who Needs Cessation Counseling When Is It Best
To Approach a Pregnant Woman
24
Assessing Physical Dependence

• Smokes within 30 minutes after waking?
• Has difficulty in places where smoking is not
  allowed?
• Find first cigarette of day is the most
  satisfying one?
• Smokes 3-5 cigarettes a day?
• Smokes more in morning?
• Smokes even when ill?
• Inhales?

25
Opportunities for Counseling Teachable Moments

• 1st trimester
• Opportunities
• During each prenatal visit
• Informing a woman of positive pregnancy test
  results
• Discussing ways to decrease morning sickness
• Ultrasound
• First visit w/ partner (if he smokes)
• Reviewing medical and social history (problems in
  earlier pregnancies may make her feel vulnerable
  and more open)

• Points to reinforce w/ client
• Its never too late to quit
• Quitting completely is best but cutting back is
  better than continued regular smoking
• Smoking increases the risk of miscarriage
• Secondhand smoke may harm the fetus too
• Having had a healthy baby despite smoking in the
  past does not guarantee the same this time
• Smoking cessation before the 16th week of
  pregnancy increases outcomes of a healthy baby

26
Opportunities for Counseling Teachable Moments

• Points to reinforce
• Its never too late to quit
• The development of the baby is taking place very
  quickly, so the mother needs to keep herself
  healthy. Quitting smoking reduces the chances of
  having a low birth weight baby
• Smoking decreases the amount of blood, oxygen and
  nutrients flowing to the fetus while exercise
  increases them
• Secondhand smoke affects the fetus
• Quitting completely is best but cutting back is
  better than continued regular smoking

• 2nd trimester
• Opportunities
• During each prenatal visit
• Hearing the babys heartbeat for the first time
• Ultrasound
• When checking for signs of intrauterine growth
• During nutritional counseling

27
Opportunities for Counseling Teachable Moments

• 3rd trimester
• Opportunities
• During each prenatal visit when checking for
  signs of intrauterine growth
• Childbirth classes
• Hospital visits
• Labor and delivery (in smoke-free hospital)
• Phasing into post-partum counseling

• Points to reinforce
• Its never to late to quit quitting even right
  before birth provides more oxygen and nutrients
  to the baby, and decreases excessive risk of
  still birth
• Nutritional needs are more important due to the
  rapid growth of the baby
• Children whose parents smoke are more likely to
  develop certain sicknesses

28
Opportunities for Counseling Teachable Moments

• Post-partum
• Opportunities
• Any telephone contacts or home visits
• Post-partum exam
• Well-baby visits
• Family planning appointments
• Child immunizations
• Parenting classes
• Hospital (post-partum unit)

• Points to reinforce
• If woman was able to quit during pregnancy
• Stress the importance of staying smoke free for
  her baby, other children in the house and herself
• Work with her to continue her exercise and diet
  plan
• Praise her efforts to remain smoke-free during
  pregnancy
• If she was able to cut down during pregnancy
• Get her to enter the next stage of quitting
  smoking
• Use exercise and diet to return to prepregnancy
  weight
• If the woman still smokes
• Counsel her not to smoke in areas where the baby
  will be placed

29
Behavior Change Model for Use in Prenatal Smoking
Cessation
30
Frame Work for Smoking CessationBehavioral
Stages of Change Model

• Precontemplation
• Contemplation
• Planning
• Action
• Maintenance/Relapse

31
Why Stages of Change?

• Behavior change is an ongoing process -- rarely
  does it spontaneously occur.
• Persons at different stages of need, therefore,
  use different behavior change strategies.
• Not all persons are equally ready to change,
  therefore counseling should be tailored to the
  individual.
• Movement from one stage to the next may be as
  important as the actual behavior change.

32
What Is Going on During The PRECONTEMPLATION Stage

• Client does not have any idea that change is
  needed .
• Education, primarily if the person is in
  precontemplation stage.
• Key -- get the person thinking about what if or,
  I didnt know that could happen.

33
Possible Outcomes for Women Who Smoke

• Fertility effects and birth outcomes
• Cardiovascular disease
• Complications with oral contraceptive (OC) use
• Cervical cancer
• Early menopause/aggravated symptoms
• Osteoporosis
• Slow healing of fractures
• Lung cancer

34
Contemplation Planning/preparation Patient
Provider Interactions

• Patient needs support to move to planning and
  action (family, friends, provider, etc.)
• Provider provides support to attempt cessation.
• Provider helps client recognize support
  structures already in place.
• Provider helps patient to develop effective
  cessation strategies.

35
READY FOR ACTION Patient Provider Interactions

• Client needs support to pick a quit date (best
  when change is already taking place, new job,
  home, etc).
• Provider needs to provide encouragement to set
  the begin change date.
• Provider needs to emphasize that change can take
  time and is a process which needs constant
  reevaluation and modification based on successes
  not failures.

36
What Factors Motivate Patient to PLAN and ACT?

• Cost/benefit to person
• What social interaction do they lose? What
  feelings do they lose?
• What do they gain? How much money do they save?
• Acute illness (asthma, etc.)
• Media campaigns
• (Reinforcing cessation messages)
• Social pressure
• Not accepted by most people currently
• Cessation events
• Classes, courses, national campaigns
• Clinician advises to quit
• Most adults look to their primary care provider
  for advice -- particularly older women

37
Withdrawal Symptoms

• Increased anger, aggression, hostility
• Loss of social cooperation
• Emotional imbalance
• Impaired psychomotor and cognitive functions
• Cravings
• Depression
• Restlessness
• Anxiety/Tension
• Impatience
• Irritability
• Excessive Hunger
• Fatigue
• Headaches
• Tremors
• Insomnia

38
Possible Cessation Strategies To Pick From For
Action Stage

• Whatever the method, let client choose what they
  believe they can do and have success with!!!!!!
• Cold turkey white knuckle method
• Taper down
• Behavior-focused group cessation
• Nicotine replacement
• Acupuncture/hypnosis/alternative strategies

39
Smoking Cessation Pharmacological Methods

• Pharmacological methods are primarily used in
  pre-conceptual service and with
  post-partum(non-breast feeding) mothers.
• The effects of these therapies during pregnancy
  are unknown at this time.
• Nicotine replacement therapy (NRT).
• Buproprion/zyban etc.

40
MAINTENANCE/RELAPSEClient Provider Interactions

• Often times the maintenance stage, although the
  longest, is the least addressed!
• Client needs help to stay smoking free.
• Provider needs to emphasize relapse prevention
  skills --
• Trigger recognition and differences between
  successes and relapse times.
• Provider needs to give the client permission to
  ask for continued support without feeling guilty
  or judged.

41
MAINTENANCE/RELAPSE Resources for Short-term
Success

• Nicotine replacement
• Telephone hotlines
• Self-help programs
• Provider follow-up

42
MAINTENANCE/RELAPSE Resources for Long-term
Success

• Maintenance components of cessation programs
  --provider consistency is the key.
• Environmental restrictions on smoking --
  reinforces current non-smoking behaviors.
• Social norms -- current trends in societys views
  of smoking.

43
Learning From RELAPSE

• When did it happen? What was different from when
  you werent smoking?
• What were you doing? What was different from when
  you werent smoking?
• Where did the first cigarette come from? (Friend,
  family member, did you purchase?)
• Did you use a cessation aid?
• Will you set another quit date? Is there a better
  time when you think you can go longer without
  smoking?

44
Counseling Help Tools
45
Basic Counseling Tools

• Orient client to the session and build rapport.
• Open ended questioning
• Who, what, when, where, how?
• Occasionally can use non-accusatory why questions
• Attending skills
• Full attention, verbal and non-verbal given to
  client
• Offer options, not directives
• Provide multiple possibilities regarding change
• Give information simply
• Avoid extensive medical terminology
• Avoid jargon
• Does the client want facts or need emotional
  reinforcement
• Summarizing and closure
• Restate any agreements or plans regarding stop
  date

46
Smoking Cessation During Pregnancy 5-15 Minute
Counseling Session (Also Refer to the 5as)

• Determine clients current smoking status .
• Review smoking-associated risks to fetus, infant
  and mother.
• Review costs/benefits to cessation and how to
  maintain current non-smoking behaviors.
• Provide self-help manual or pamphlet.
• Note smoking status in chart.
• Review status throughout pregnancy and support
  any positive changes the patient has made.

47
Behavior Change Model
48
Behavior Change Model
Precontemplation
Contemplation
Maintenance
Preparation
Action
49
5 As for Providers-- A Counseling ToolBased on
The Stages of Change Model

• ASK/ASSESS about smoking at every opportunity --
  reinforce non-smoking behaviors
• Determine current level of smoking
• Smoking patterns of family members
• Past attempts to quit smoking
• Current stage in the change model
• ADVISE/EDUCATE all smokers to stop and reinforce
  positive stop smoking messages
• Clear message to quit
• Effects of smoking on mother and child
• Health benefits of quitting
• ASSIST the patient in stopping -- help the
  patient through the contemplation, preparation
  and action stages of changes
• ARRANGE follow-up visits -- for reinforcement of
  behavior changes and modification to plan if
  necessary

50
A- ASK/ASSESS

• Assess clients current level of smoking
• Ask
• When have thought about quitting in the past or
  since you found out youre pregnant?
• When was the last time you had a cigarette?
• How many cigarettes did you smoke yesterday?
• Why do you think it would be a good idea to quit?
• What has kept you from quitting in the past?
• What do you know about how smoking effects both
  you and your baby?
• Assess/ask about smoking patterns in her family
• Assess/ask about any past attempts to quit
  smoking or cut down
• Ask
• Although you may feel that you failed, you were
  just practicing quitting. You actually increase
  your chances of remaining an ex-smoker with each
  try
• What caused you to start smoking last time?
• What could you do instead of smoking the next
  time this happens?

51
A- ASK/ASSESS (Continued)

• Identify her current state in the quitting
  process
• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance / relapse
• Record accurate history of smoking cessation
  patterns

52
A-ADVISE

• Give the client a clear message to quit
• I strongly advise all of our pregnant smokers
  to quit. Your baby will get more food and oxygen
  to grow better and you will feel more energetic
  now and after the baby is born.
• Discuss the health benefits of quitting
• See reference materials for information
• Discuss the effects of smoking on both the smoker
  and children

53
A-ASSIST

• If she is in the precontemplation stage (little
  or no interest in quitting)
• Help her begin to think of reasons why she might
  want to quit smoking sometime in the future
• Ask
• What have you heard about quitting?
• Do you know anyone who has quit?
• What are your concerns or questions about
  quitting?
• If she is willing, brainstorm reasons why she
  should quit for herself and her baby
• Emphasize social, economic, and health benefits
  rather than negative health effects
• If she is in the contemplation, preparation or
  action stage (thinking about quitting or ready
  to quit in the near future)
• Inform her of the health benefits of not-smoking
• Help her find ways to deal with the barriers that
  keep her from quitting. Help her set a quit date

54
A-ASSIST (Continued)

• Respond to specific concerns she may have
• Concern
  Response
• Stress
• Pregnancy can be a stressful time. If youre
  worried about not having cigarettes to relieve
  your stress, lets think about other ways you can
  deal with stress. What else has worked for you
  in the past?
• Others smoking around the client
• How can you ask your family/friends not to
  smoke near you or to go outside and smoke since
  their smoke can harm the baby? How do you think
  they would react?
• Weight gain
• Not all women gain weight when they quit
  smoking. And a little weight gain is normal
  during pregnancy.
• Withdrawal symptoms
• Not all smokers have withdrawal symptoms-
  also called signs of recovery. If you have any
  symptoms, they will lessen over time.

55
A-ASSIST (Continued)

• If she is ready to quit
• Give her current written materials
• Explain most successful quitters had a plan to
  help them quit. Lets go over these 8 simple
  steps so you can make your own quitting plan
• What are your reasons for quitting?
• When and where do you smoke?
• List three daily habits associated with smoking
  you can change
• Choose three cigarette substitutes you would like
  to use
• Deep breathe
• Drink water
• Do something else
• Discuss/talk with a friend or family member
• Delay smoking
• List how you will treat yourself with the
  cigarette money youve saved
• List people you can ask to support your efforts
  to quit smoking (give her the number and first
  step hotline at 1-800-367-2229)
• Make a contract with yourself starting on quit
  day, you will not beg, bum or borrow anyone
  elses cigarettes. If you decide to smoke, you
  will buy and smoke your own cigarettes
• Set a quit date
• If she has been able to cut down
• Say Its great that you were able to cut down.
  Lets work toward the day you can stop smoking
  completely. Now, lets set a schedule for next
  week -- how many cigarettes will you smoke a day
  and when? I think your efforts to cut down have
  been great, congratulations.

56
A-ASSIST(Continued)

• If she is in the maintenance stage (has already
  quit)
• Ask about long term plans regarding smoking
• What are your plans regarding smoking once your
  baby is born?
• Be aware many women take pregnancy pauses in
  smoking!!!!
• Help her refine her list of coping strategies
• Stress
• Support structures
• Smoking friends and/or family
• Talk to her about after the baby is born
• Cigarette temptation
• Weight
• Breast feeding
• If she is feeling angry or sad
• You might say this feeling is normal. Many
  smokers state that they feel this way after
  quitting. Smoking was an important part of your
  life and you feel a loss when it is gone
• If she wants to try just one

57
A-ASSIST (Continued)

• If she is in relapse stage (had a few cigarettes
  or has gone back to smoking)
• Help her stop the relapse and get back to trying
  to quit.
• What you might say youve just had a slip.
  Dont worry about the few youve smoked, youve
  been smoke free for _____ amount of time - you
  can do it again.
• If she has relapsed completely, help her get back
  into the quitting process again move her into the
  action stage quickly. Stress the progress she
  has made and refine her quit plan.
• Remind her about multiple attempts before
  quitting - each time she will get farther.
• Get her to explain why she is trying to quit to
  begin with -- health benefits to her and the baby.

58
A-ARRANGE

• Arrange follow-up
• If she is not ready to quit
• Understanding of quitting being a hard and
  difficult decision.
• Have client think about it and discuss at next
  visit.
• If she has agreed to try to quit smoking
• Make a note -- give additional materials provide
  support phone s.
• Explain you will discuss how she is doing at next
  visit.
• If she has already quit smoking
• Make a note to continue dialogue about her not
  smoking at next visit to discover any relapse or
  areas of resistance.

59
Behavior Change Model
Precontemplation
Contemplation
ASK/ASSESS
ADVISE
ASSIST
ARRANGE FOLLOW-UP
Maintenance
Preparation
Action
60
Helpful Cessation Checklist for Health Care
Setting

• Designate a smoking cessation coordinator
• Create smoke-free office
• Identify all patients who smoke
• Have self-help materials on hand
• Develop an intervention and follow-up protocol

61
Office Systems for Tracking Client Progress

• Flow charts/smoking history (reviewed by provider
  and client -- can be used as a reinforcement for
  a clients behavior changes)
• Provider reminder/chart sticker
• Client reminder

62
GOING to ASmoke FREE Office

• Develop a policy set the date
• Communicate with staff and clients
• Post no smoking signs
• Remove ashtrays
• Display tobacco education materials
• Follow-up

63
Locating Smoking Cessation Referral Resources-
National and Local

• American Lung Association freedom from smoking
• American Cancer Association fresh start
• Community Hospitals/HMOs
• 1-800-4-CANCER

64
Counseling Concerns

• Can I really make a difference?
• Yes! The counselor can provide the smoker with
  the encouragement and support they need to
  progress through the stages of quitting. A
  helping hand can most definitely make a world of
  difference to someone who is changing life long
  habits.
•  
• I do not have time to learn how to counsel.
• The information in the packet will give you
  enough information so you feel knowledgeable and
  comfortable with counseling smokers to quit.
  Assess/Ask, Advise, Assist and Arrange are the 5
  A's method used to help your client become smoke
  free.
•  
• Who should do this counseling?
• Counseling is most successful when the team
  approach is used. The more people who
  participate in the counseling the better the
  outcome will be. Using a combination of
  person-to-person counseling, written materials
  and follow-up telephone contacts have been found
  to be the most effective approach.
•  
• Can providers who smoke or have never smoked
  counsel effectively?
• If you have not smoked before, be prepared to
  answer questions concerning your expertise on the
  challenges of quitting smoking. Try to share
  other ex-smokers experiences. If you do smoke
  and feel uncomfortable counseling, the client may
  not feel your are a credible source so you
  probably will not be an effective counselor. You
  should not counsel if you do not feel you can
  make an impact.

65
Counseling Concerns

• Smokers often resist counseling. What can I do?
• Do not push the woman beyond what she is willing
  to discuss. Concerns about previous quitting
  attempts or making a plan to quit should be
  addressed immediately. Quitting smoking involves
  physical and psychological addiction so you must
  be there for their support.
•  
• What if the smoker has other unhealthy behaviors?
• Give her all appropriate health information and
  help her set her own priorities.
•  
• How do I find time to counsel smokers?
• Counseling sessions as brief as three to ten
  minutes can be effective. Incorporate your
  smoking cessation counseling when doing history,
  physical exam or routine guidance. Every
  interaction has an impact on the smoker even if
  there is not time to provide materials or have a
  discussion.
•  
• Where do I begin?
• You already have. Reading this guide is the
  first step. You must first assess the current
  level of smoking, family-smoking patterns, past
  attempts to quitting and current stage of
  quitting. Advising and educating your client on
  health consequences of smoking, the benefits of
  quitting, and the effects of smoking on children
  and the mother would then be the next step. You
  then must assist in the stages of change.
  Arrange a follow-up to evaluate the counseling
  process. 

66
Identifying Counseling Observations and
Techniques

• Observing Non-verbal Cues
• Turning Body Away
• Playing with Objects
• No Eye Contact
• Long Silence Between Responses
• Pacing
• Rocking
• Intense Gestures Towards Counselor
• Intense Facial Grimacing
• Observing Verbal Cues
• Quick Denial
• Hostile
• Inconsistency
• Jokes Out of Context
• Changes Pace
• Blames Others
• Angry
• Refuses To Answer

67
SUGGESTIONS Reaching Pregnant Smokers

• Points to Ponder Before Beginning to Counsel
•  
• Pregnancy is the ideal time to counsel smokers to
  quit. Women are often motivated to quit to
  protect the health of their unborn babies.
  However, it is important to address the benefits
  of quitting for both the mother and the baby.
  Otherwise, the mother may be able to quit during
  pregnancy but is likely to resume smoking after
  the baby is born.
•  
• Some women who smoked during an earlier pregnancy
  may already have a healthy baby/child or may have
  friends who smoked during their pregnancies and
  have healthy babies. Since all pregnancies are
  different, emphasize that she increases her
  chances of having a healthy baby this time if she
  stops smoking.
•  
• NOTE Currently, use of the nicotine replacement
  therapy (patch or gum) is not recommended for
  pregnant (or breastfeeding women).
•   

68
SUGGESTIONS Reaching Pregnant Smokers

• Counsel From Your HEART as Well as Your Head
•  
• 1.     Take time to build rapport. Be warm,
  friendly and caring. Show respect for the woman
  and what she says and feels. Find out what the
  clients values and needs are. Be concrete and
  specific in your responses.
•  
• 2.     Be positive and non-judgmental. Some
  women fear you may criticize and lecture them
  about smoking. Acknowledge that it is not easy
  to quit but encourage her that she will be able
  to quit smoking and that you have confidence in
  the ability to do this. Suggest she talk to
  ex-smokers about how they quit. If she has tried
  to quit before, focus on the positive aspects of
  her previous practice quit attempts rather than
  on her feelings of failure.
•   
• 3.     Focus on other positive lifestyle changes
  she has made (losing weight, wearing a seatbelt
  or healthy eating) to build her confidence.
  Smokers who believe they can quit are the ones
  who succeed.
•  
• 4.     Focus on the womans feelings and
  behavior. Every pregnant woman has some worries
  about her pregnancy, her bodily changes, and
  fatigue. Allow her to discuss her concerns and
  reassure her that such feelings are normal.
•   
• 5.     Remember that stressful situations in a
  womans home or work life (like violence,
  harassment, etc) may contribute to why she smokes
  or why she finds it hard to quit.
•  
• 6. Encourage support from others. Ask her to
  identify family members and friends who can help
  her stop smoking. Together, brainstorm ways to
  ask for help. Discuss whether her partner or
  close friends smoke. If they do, talk about
  things they can do to help her, like not smoking
  around her or quitting also. If she has no other
  support, you may want to offer yourself as a
  support person.

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KEY POINTSCounseling Women Who Smoke

• Counseling is most effective when you join with
  the woman as her partner to develop a
  personalized quitting plan. Having a plan is the
  critical component in successful quitting.
•  
• Assess how ready each woman is to quit and tailor
  your counseling accordingly.
•  
• Problem-solve together to break down each womans
  barriers to quitting. Listen well. Help her
  come up with her own answers rather than imposing
  your ideas.
•  
• Quitting is a process that may occur over a
  number of quit attempts. View these attempts as
  practice where she learns what her triggers are
  and what coping strategies work (or dont work).
•  
• Women are most likely to succeed when they
  believe they can successfully quit or cut down.
  Your confidence in each womans ability to quit
  successfully will increase her confidence in
  herself.

70
KEY POINTSCounseling Women Who Smoke

• Most women know that smoking is bad for them but
  they need support.
•  
• Women place a high value on a personalized,
  one-on-one approach to receiving new information.
  They prefer receiving advice to stop smoking if
  it is provided in a caring, personal way by
  someone who offers support, avoids blame and
  guilt, and addresses their personal needs.
•  
• It is important to take time to develop rapport
  and put each woman at ease. Use a conversational
  tone of voice, establish eye contact, sit next to
  her, and smile.
•  
• Women with a lower educational level, who lack
  support, or who live with a smoker may have the
  most difficulty quitting.
•  
• Regardless of whether a woman is pregnant, a new
  mother, or thinking about pregnancy, there are
  health benefits for both her and her
  baby/children when she quits smoking.