interventions for smoking during pregnancy patricia cluss, ph.d. pittsburgh mind-body center summer...
TRANSCRIPT
![Page 1: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/1.jpg)
Interventions for Smoking During Pregnancy
Patricia Cluss, Ph.D.
Pittsburgh Mind-Body Center
Summer Institute 2007
![Page 2: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/2.jpg)
Review of AHCPR/PHSSmoking Cessation Guideline
(1996 & 2000)
• Effective smoking cessation treatments exist• Every smoker should be offered an effective
treatment• Health care clinicians: screen for tobacco use
status of every patient • Brief cessation treatments are effective; at
least a minimal intervention should be provided to every smoker.
![Page 3: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/3.jpg)
Effective Treatment
• Three effective treatment elements: pharmacological aides, social support, skills training/problem solving
• Dose-response relationship: More intense treatment = greater effectiveness
• Identify and intervene with smokers at every health care visit
![Page 4: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/4.jpg)
Pharmacotherapies
• Nicotine replacement therapies (patch, gum, lozenge, nasal spray, inhaler)
• Zyban (Wellbutrin/bupropion)
• Chantix (varenicline)
![Page 5: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/5.jpg)
Key components of programs for all smokers
• Information• Behavioral problem solving skills• Coping strategies• Attention to motivation and readiness• Social support• Relapse prevention
![Page 6: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/6.jpg)
The 5Asfor Health Care Settings
• Ask
• Advise
• Assess
• Assist
• Arrange
![Page 7: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/7.jpg)
5A Results
• Provider Ask rates have increased from 10-30% a decade ago to about 60% in 2004.
• Advice rates to identified smokers is about 70% now
• Rates of the last 3 of the 5As continue to be poor.
![Page 8: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/8.jpg)
Other Mnemonics / Plans
• Ask, Advise and Refer
• Ask and Act
Expert committee has been reconvened for a guideline update within next several years
![Page 9: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/9.jpg)
SMOKING DURING PREGNANCY
![Page 10: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/10.jpg)
Health RisksSmoking during pregnancy is one of the major preventable risk factors for perinatal morbidity
and mortality:• Intrauterine growth retardation (low birth
weight, length, head circumference)• Increased risk for ectopic pregnancy,
miscarriage and premature delivery• Adverse long-term effects on children’s
neurocognitive development• Adverse effects on postnatal height growth• Postnatal impaired arousability from sleep
(associated with SIDS)
![Page 11: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/11.jpg)
Smoking during Pregnancy as a Health Care Crisis for the Underserved
• Reducing smoking during pregnancy by 1% in U.S. over 7 years would prevent 57,000 LBW infants and save $572M in direct medical costs.
• Low SES women are much more likely to smoke during pregnancy (23%) than higher SES women (5%).
• At MWH prenatal clinic, 50% of pregnant women smoke.
![Page 12: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/12.jpg)
How many women smoke during pregnancy?
• Prevalence between 1987 and 1996 reduced from 16% to 12%.
• Pregnant women are about half as likely as nonpregnant women to be smokers.
• The median number of cigarettes smoked for pregnant women has remained a fairly constant 10/day.
![Page 13: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/13.jpg)
Who smokes during pregnancy?(Race & ethnicity)
21
17
10
43
0
5
10
15
20
25
American Indian
White
Black
Hispanic
Asian-PacificIslander
%
Source: National Center for Health Statistics
![Page 14: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/14.jpg)
Who smokes during pregnancy?
15
912
8
19
23
16
5
9
14
0
5
10
15
20
25
Age Married? Education Employed?
Age:Teen/21-30/>30 Married: yes/no
Education:< hs/hs grad/> hs Employed: yes/no
%
![Page 15: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/15.jpg)
Who smokes most during pregnancy?
Low SES women,regardless of how SES is measured
• Least educated: high school or less• Lowest income: women on Medicaid are
2X as likely to smoke as those with private insurance
• Of employed women, those with the lowest status jobs (5X greater than those with highest status jobs)
![Page 16: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/16.jpg)
Who quits when pregnant?
• 25% quit when they become pregnant (spontaneous quitters)
• Lighter smokers• Older• Having their first baby• Smoking for a shorter amount of time• Higher education level• Higher SES• Partner who is a nonsmoker
![Page 17: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/17.jpg)
The good news & the bad news
The Good News
With increased availability of information about the harmful effects of smoking, more women are aware of the value of quitting before or at the beginning of a pregnancy.
The Bad News
For those who don’t,
it’s hard.
![Page 18: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/18.jpg)
• Quitting any time during pregnancy is beneficial
• More intensive interventions are preferred
PHS Guideline recommendationsfor pregnant smokers:
![Page 19: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/19.jpg)
Cutting Down as a Goal for Pregnant Smokers?
Substance abuse
Nonpregnant smokers
Alcohol abuse
Pregnant smokers:dose-response relationship
![Page 20: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/20.jpg)
What works?
• Tailoring the intervention for pregnancy
• Brief counseling of 5-10 minutes
• Nicotine replacement therapy, Zyban, or Chantix???????
• Provide cessation interventions for smoking partners??
![Page 21: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/21.jpg)
Working with low SES pregnant smokers
• Cessation programs are less effective for low vs. high SES smokers
• Low SES women report more stressful events, more perceived stress, more negative appraisal from family, less social support & higher addiction to nicotine
![Page 22: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/22.jpg)
These conditions result in lower:
Motivation to stop smoking
&
Confidence in their ability to stop
![Page 23: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/23.jpg)
Relapse
• 15-30% relapse during pregnancy
• 55-70% relapse within 1 year postpartum
• 60% of those relapse within 1 month
![Page 24: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/24.jpg)
Factors associated with relapse
• Decreased motivation to be a nonsmoker in the postpartum
• Decision not to breastfeed/short duration of breastfeeding
• Concern about losing weight in the postpartum
• Changes in social support for not smoking
![Page 25: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/25.jpg)
Interventions for low SES pregnant smokers should include:
• More intensive interventions• Focus on reducing stress • Identification of depression & other MH
needs• Increased focus on social support• Attention to postpartum relapse
![Page 26: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/26.jpg)
Problems with Screening During Pregnancy:
• 14% of privately insured women do not disclose that they smoke
• 25%-40% of women seen in public maternity clinics do not disclose
![Page 27: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/27.jpg)
Improving the validity of self-report of smoking status
“Do you smoke?”• I smoke about the same as or more than before
I was pregnant• I’ve cut down since I found out I was pregnant• I have quit smoking since finding out I was
pregnant • I wasn’t smoking around the time I found out I
was pregnant and I don’t currently smoke
![Page 28: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/28.jpg)
Pittsburgh’s Least Well-Known Claim to Fame:
#1 in smoking during pregnancy
of any large US City*Pittsburgh 24%
NYC 5%
Boston 8%
Chicago 10%
Philadelphia 18%
Cleveland 20%
Top 50-city avg. 11%
Source: Annie E. Casey Fdn. Kids Count Special Report, 1999
![Page 29: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/29.jpg)
The Pittsburgh STOP (Stop TObacco in Pregnancy) Program
• An outcomes-driven evidence-based program for underserved pregnant smokers
• Almost 900 pregnant smokers and recent quitters have participated since 2000 (60%/40%)
• Based at WPIC with community outreach at Magee-Womens Hospital and other community locations
![Page 30: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/30.jpg)
Pittsburgh STOP ProgramReadiness-based recruitment &
intervention strategies
Sure you can’t/don’t want to quit, butwilling to think about cutting down?
Thinking about quitting, but not sure?
Ready to quit?
![Page 31: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/31.jpg)
Race/Ethnicity
55
40
41
0
10
20
30
40
50
60
White
Black
Biracial
Asian
%
![Page 32: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/32.jpg)
Pittsburgh STOP Program
• Mean age 23; range from 14-42• Marital status: 83% single• Education: 41% did not graduate HS• Income: 56% have yearly income < $10K• Insurance: 91% Medicaid or uninsured• # other children: avg. = 1; range 0-7• Pregnancy unplanned for 85%• D&A: 35% admit concurrent use• Current domestic violence: 20%
![Page 33: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/33.jpg)
STOP ProgramInnovative features in the STOP Program:
• Incentives:– Small baby gift for attending sessions– Small gift for self for meeting cessation or
cut-down goals
• Exhaled air carbon monoxide (CO) monitoring
![Page 34: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/34.jpg)
CO Monitoring
• Originally built into the design as an evaluation measure to confirm self report of smoking status
• Initial concern about effect of this measure on participant-interventionist relationship
![Page 35: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/35.jpg)
What has been most helpful?
IncentivesProblem solving
2%
Support from interventionist 31%
Education on health effects of smoking
13%
Saw how cutting down improved my
health 4%
CO monitoring 43%
Other2%
5%
![Page 36: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/36.jpg)
CO Monitoring
• Based on participant feedback, CO monitoring is now used as a program element to motivate change.
![Page 37: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/37.jpg)
STOP Participants’ CO LevelsAll those who entered as smokers
20
13
0
2
4
6
8
10
12
14
16
18
20
Intake 3rd session
A CO score of 8 or less is indicative of no smoking
![Page 38: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/38.jpg)
Smokers’ Pre-delivery CO Levels
Those with 3 or more pre-delivery readings
19
11
0
2
4
6
8
10
12
14
16
18
20
Intake Last pre-delivery session
CO score of 8 or less is indicative of no smoking
![Page 39: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/39.jpg)
CO Monitoring as a Motivator
• Baseline score with printed and verbal info about how higher levels of CO/lower levels of oxygen affect the mother and the fetus
• Used as an example of other harmful physiological effects of smoking on mother and fetus
• Weekly CO goals
• Chart for ongoing CO monitoring
![Page 40: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/40.jpg)
STOP Program Results
• Drop out rate low at 14%• Quit & stay quit rates:
– 26% quit rate for those who enter as current smokers; most who do not quit do cut down
– 93% stay-quit rate for those who enter as recent quitters
• Birth outcomes ex-smokers vs. smokers:– Significantly higher birth weights (11 oz.): only
13% born LBW vs. 24% for smokers (p=.02)– Longer gestational age (38 vs. 37 weeks): only
24% born preterm vs. 34% for smokers (p=.10)
![Page 41: Interventions for Smoking During Pregnancy Patricia Cluss, Ph.D. Pittsburgh Mind-Body Center Summer Institute 2007](https://reader036.vdocuments.mx/reader036/viewer/2022062804/56649d845503460f94a6a83a/html5/thumbnails/41.jpg)