predictors of smoking cessation among pregnant women in san bernardino county

Running Head: PREDICTORS OF SMOKING CESSATION AMONG PREGNANT WOMEN

IN SAN BERNARDINO COUNTY

SCHOOL OF PUBLIC HEALTH | GLOBAL HEALTH DEPARTMENT

Loma Linda University

School of Public Health

FIELD PRACTICUM REPORT

Title:

Predictors of Smoking Cessation among Pregnant Women in San Bernardino County:

An Analysis and Evaluation of the Loma Linda Medical Center Perinatal Institute

Comprehensive Tobacco Treatment Program

Presented to the

LLU SPH Department of Global Health and Epidemiology

In partial fulfillment of the requirements for the MPH degree

By:

Temidayo O. Ogunrinu, B.S., MPH (c)

Date:

December 12, 2013

To Faculty Reader:

Pramil Singh, DrPH

Field Supervisor:

Gretchen Page RN, MPH, CNM

Manager, RPPC & CDAPP Programs

PREDICTORS OF SMOKING CESSATION AMONG PREGNANT WOMEN IN SAN

BERNARDINO COUNTY 2

Statement of Original Work

“I hereby declare that the field practicum submission is my own work and to the best of my knowledge it

contains no materials previously written or submitted to the Global Health Department by another

person, except where acknowledgment is made in the report. I also declare that the intellectual content of

this field practicum report is the product of my own work, except to the extent that assistance from others

in report design and formation, presentation, and linguistic expression is acknowledged.”

Student Signature: Temidayo Ogunrinu Date : December 11, 2013


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Table of Contents

Definition of Terms………………………………………………………………………... 4

Abstract…………………………………………………………………………………..... 5

Background……………………………………………………………………………....... 6

Aims……………………………………………………………………………………..… 9

Methods……………………………………………………………………………………. 9

Results……………………………………………………………………………………... 12

Discussion…………………………………………………………………………………. 17

Limitations………………………………………………………………………………… 18

Recommendations…………………………………………………………………………. 19

Evaluation of Field Practicum…………………………………………………………....... 19

References…………………………………………………………………………………. 23

Appendices………………………………………………………………………………… 24


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Definition of Terms

CTTP- Comprehensive Tobacco Treatment Program

FG- Focus Group

LLU-Loma Linda University

LBW-Low birth weight

PTB-Preterm birth

SIDS- Sudden Infant death syndrome


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Abstract

Maternal smoking has many adverse health outcomes, particularly on the unborn child. These

outcomes include low birth weight, sudden infant death syndrome and pre-term birth. Several

studies show that if mothers reach smoking cessation it will significantly decrease these birth

effects. San Bernardino County, the largest county in California has a high rate of maternal

smoking. Currently there is no comprehensive maternal smoking program that serves in this

county except for the Comprehensive Tobacco Treatment Program (CTTP). In 2013 a

retrospective cohort study was done on 233 participants who enrolled in this CTTP from 2012-

2013. Eighty-two percent of the participants who completed the program retain smoking

cessation at their last point of follow up. With these findings investigator sought to determine

which the characteristics made participants successful or unsuccessful in completing the

program. Quantitative analysis was carried out using SAS 9.3 to statistically determine women in

their first and third trimester are less likely to complete the program. Additionally, Whites and

Blacks, had a higher odds of non-completion as well as those who are younger in age. Major

themes in the Focus determined that family of maternal smokers should be incorporated and

more resources to support transportation to the program should be provided.


BERNARDINO COUNTY 6

Background

Maternal smoking during pregnancy is associated with numerous adverse health effects

particularly for unborn infants. These health effects include but are not limited to infant low birth

weight (LBW), sudden infant death syndrome (SIDS), preterm birth(PTB), and neurological and

cognitive delays which contribute to the increase in neonatal and infant mortality (Cnattingius,

2004). Despite smoking being one of the most modifiable risk factors for disease, the World

Health Organization (WHO) reported that the global maternal rate of smoking has skyrocketed to

12 million as of 2001 and increased to 200 million as of 2006 (Pregnets, n.d.) (WHO, 2001). In

addition, within the United States women smoked nearly the same rate as men and although

smoking rates have decreased among women as of 2004 an estimated 22% of women in

reproductive age smoked(WHO, 2001) (The 2004 united states surgeon general’s report: the

health consequences of smoking, 2004). In 2010 The Centers for Disease Control and

Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR) reported that among 27

US States, 10.7% of women smoked the last trimester of their pregnancy. They also reported that

of the 10.7% of women who smoked during their pregnancy 54.3% quit while pregnant and

15.9% continued to smoke after delivery (MMWR, 2010).

The California Department of Public Health (CDPH) reported their maternal smoking

prevalence was 8.1% which compared to the national average of 10.7% is lower. This was

assessed using the Maternal and Health Assessment (MIHA) Survey, an annual population-based

survey of women with a live births (CDPH, 2011).

In 2007 and 2008 a study carried out in San Bernardino County identified a total of 2,785

mothers who smoked during pregnancy using de-identified birth cohort files. The study found


BERNARDINO COUNTY 7

that the prevalence of maternal smoking was 6.3% while smoking cessation was 2.0% (Batech,

et al, 2013). In 2010 The MIHA survey also determined that within San Bernardino County there

has been no decline, rather the prevalence of maternal smoking has increased to 8.8%. Although

San Bernardino County does not have the highest percentage of maternal smoking, it is higher

than the California average of 8.1% (CDPH. 2011).

Researcher such as Batech studied that maternal smoking cessation significantly lowers

the risk of LBW, SIDS and PTB (Batech, et al, 2013). Unfortunately, smoking cessation and

relapse prevention are a challenge for many. Some are successful without the use of evidence-

based cessation treatments but others may need these interventions. Such proven interventions

include:

Brief clinical interventions (i.e., when a doctor takes 10 minutes or less to deliver advice

and assistance about quitting)

Counseling (e.g., individual, group, or telephone counseling)

Behavioral cessation therapies (e.g., training in problem solving)

Treatments with more person-to-person contact and intensity (e.g., more time with

counselors)

Cessation Medications (CDC, 2013).

Programs that include some or all of these aspects are useful and serve as a great need.

Currently, San Bernardino County has only one smoking cessation and relapse prevention

program. This program is a First 5 San Bernardino funded program developed by Loma Linda

University Medical Center/Children’s Hospital called the Comprehensive Tobacco Treatment

Program (CTTP). Their main objective is to accomplish smoking cessation and/or relapse

prevention among pregnant women who are currently smoking or have smoked cigarettes during


BERNARDINO COUNTY 8

the previous 6 months of enrolling in the program. This is an eight (8) week program that screens

pregnant women within selected sites in San Bernardino County. These sites include outpatient

clinics and rehabilitation homes. Once individuals enroll in the CTTP, health educators assess

their smoking status, risk for maternal depression and substance abuse use. An individualized

plan is developed which allows participants to set a quit date and other goals that will enable

their smoking cessation. The health educators provide each participant with health education

regarding tobacco use and the benefits of smoking cessation. The participants are then given

weekly incentives for every week they test negative to a urine tobacco test. The incentives

include diapers and xylitol gum. Once participants complete the program they are followed up at

3, 6 and 9 months.

Currently the CTTP serves 233 clients within several cities within San Bernardino

County. They have one form of evaluation which captures infant health outcomes such as LBW,

neurological and cognitive skills, and whether clients completed the program. However, they

have no evaluation that assess the efficacy of their program. In 2013 a School of Public Health

Student interned with the CTTP to evaluate the programs efficacy. She researched that there

were several studies which identified certain characteristics or predictors that make maternal

pregnant smokers more successful to quit and not relapse. These predictors include Socio-

demographics such as age, education level, marital status, social status, gestational age, parity,

level of smoking, willingness to quit, years of smoking, and partners smoking status and

ethnicity (Woodby, 1999) (Severson, Andrews, Lichtenstein, Wall, & Zoref, 1995). After

assessing the programs efficacy they wish to identify which of these characteristics or predictors

have the most significant impact on their participant’s success or lack of within the program.


BERNARDINO COUNTY 9

This analysis will allow them to modify the program toward individuals who are less likely to

complete yielding better success rates.

The specific project aims are:

1) To identify demographic, behavioral, and gestational variables associated with

successful completion of the CTT program.

2) To assess the efficacy of program enrollment on achieving smoking cessation or

relapse prevention at three or more months of follow-up.

3) To assess the efficacy of program completion on achieving smoking cessation or

relapse prevention at three or more months of follow-up.

Research Questions

1. What are the characteristics among the program population that predict program non-

completion?

Hypothesis 1: Those who have a willingness to quit as measured by smoking status at enrollment

are more likely to complete the program

Methods

To assess the efficacy of the CTTP and identify the predictors that contribute to

successful completion and non-completion, qualitative and quantitative data most be collected

and analyzed applying the skills utilized from epidemiology, biostatistics and global health

courses. A literature review was conducted before quantitative and qualitative methods began to

guide methodological framework and to ensure research is not contrary to similar and previous

studies carried out.


BERNARDINO COUNTY 10

Qualitative

A focus group (FG) guide was created in collaboration with the CTTP staff. This can

found in Appendix A. The FG guide was intended to uncover 5 key themes; participants smoking

backgrounds, barriers or challenges participants faced towards their smoking cessation, areas of

CTTP program effectiveness that contributed to their smoking cessation, aspect of the program

that had the biggest impact and areas the programs can improve in. Flyers inviting participants to

join the FG were created and distributed at each site except Spanish speaking cites. Those

interested were instructed to RSVP so that enough incentives and refreshments could be planned

accordingly. The FG took place at the Mountain View Plaza (MVP), which is the home of the

CTTP. The FG was conducted with a facilitator and a note taker. All questions in the focus group

were open ended and discussion based. The FG was recorded and the participants were

instructed that the FG would be kept confidential. Each client signed a consent form. A copy of

the consent form can be found in Appendix B.

Data analysis

Following the focus group the tape recording was transcribed verbatim. Additional notes

from the note taker were also compiled together to assist with the analysis. To analyze the

transcription an A priori code book was created to identify the most essential emerging themes

concerning. The code book can be found in Appendix C.

Quantitative

Study population

The current study is based on a cohort of 233 pregnant women from the county of San

Bernardino enrolled in the CTTP program between 2012 and 2013. Twenty two participants with

missing data on program completion status were excluded from the analysis.



Program completion data

Subjects were designated to have completed the program if they stayed quit for 8 cumulative

weeks. In addition regardless of their completion status, subject was contacted at 3, 6 and 9 months

interval and their smoking status (yes/no) was assessed.

Covariates

Gestational age was categorized into trimesters, women with gestational age <13 were

classified in the first trimester; those between 13 and 28 were classified as second trimester and

those above 28 as third trimester. Smoking status at enrollment indicates whether the participant

was still smoking or not on the day of program enrollment. The race variable had the following

four levels: Asians, Blacks, Hispanics and Whites. Age was used as a continuous variable.

Statistical analysis

Simple logistic regression was used to assess the effect of individual socio-demographic

variables on program completion. Two multiple logistic regression analysis were conducted; the

first assessed the effect of smoking status at enrollment age race on program completion. The

second analysis looked at the adjusted effects of gestational age race and age on program

completion. All the analysis was done with SAS 9.3.

Results

Qualitative

The FG revealed that each of the participants had a long history of smoking starting in

their teenage years and even as young as nine years old. For most of the participants, peer

pressure from friends or family is what triggered their initial smoking. Drugs and alcohol also

played a huge role in their smoking habits. Each of the participants had stopped smoking

between one month and one week prior of starting the program. Additionally, they each had



attempted to quit smoking at one point before they started the CTTP program. They all

completed the program. The majority of the participants felt that their experience with the CTTP

program was positive experience. They all felt that the educational materials used were relevant

and made a significant impact for them to not smoke. The incentives played a role, but was not

biggest role in their smoking cessation. However the motivation the health educators gave them

did. The biggest motivating factor was wanting to be alive and healthy for their children which

they all expressed that the CTTP program helped them realize. Because the majority of these

participants where either in a live in facility or where patients at Loma Linda Medical Center, or

the diabetes center they all felt that it was very convenient to see the health educators. The only

concern came from a participant who no longer was a client at a particular facility and did not

have adequate transportation to be seen at the Mountain View Plaza (MVP). This was expressed

as a barrier. Other participants expressed it would be beneficial to include family members

especially significant others in the program, so that they too could act as a motivator to quit

smoking. In addition if their partners were smokers it could help the both of them reach smoking

cessation.

Quantitative

Figure 1: CTTP Participation completion status and follow ups



Table 1: Demographic, Behavioral, and Gestational Variables among enrollees in the CTTP

Program (San Bernardino County, California) during 2012-2013.

N (%)

Age category

20 or younger 41(17.67)

21-25 96(41.38)

26-30 50(21.55)

31 or older 45 (19.4)

Total 232

Gestational age at enrollment

First trimester 32(14.04)

Second trimester 89 (39.04)

Third trimester 107 (46.93)

Total 228

Race/Ethnicity

Asian/Other 15 (6.47)

Hispanic 107(46.12)

NH Black 38(16.38)

NH White 72 (31.03)

Total 232

Education

9th Grade or less 61(34.66)

High school graduate 64 (36.36)

College education or more 51 (28.98)

Total 176

Income

Less than $10,000 69(51.49)

$10,000-$25,000 40 (29.85)

More than $25,000 25(18.66)

Total 134

Single parent No Yes

No 65 37.14

Yes 110 62.86

Total 175

Partner smokes No Yes

No 100 45.66

Yes 119 54.34



Total 219

Number of cigarettes at enrollment No Yes

Quit 159 68.83

>= 1 Cigarette 72 31.17

Total 231

Drug use No Yes

No 140 76.5

Yes 43 23.5

Total 183

Alcohol use No Yes

No 96 52.46

Yes 87 47.54

Total

Smoking status at enrollment No Yes

No 153 67.7

Yes 73 32.3

Total 226

Number of pregnancies No Yes

1 or none 63 27.75

2 48 21.15

3 40 17.62

4 35 15.42

5 or more 41 18.06

Total 227

Number of children No Yes

None 80 35.09

1 60 26.32

2 39 17.11

3 or more 49 21.49

Total 228

Cite No Yes

L. Linda 78 33.62

H. Desert 76 32.76

S. Bernardino 54 23.28

Fontana/Rialto 24 10.34

Total 232



Table 2: Univariable Odds Ratios relating selected variables to Program Non-completion among

enrollees in the CTTP Program (San Bernardino County, California) during 2012-2013.

95% Confidence limits

Age OR LL UL

20 or younger vs. 21-25 0.63 0.26 1.51

26-30 vs. 21-25 0.59 0.26 1.33

31 or older vs. 21-25 0.33 0.15 0.75

Race

Asian/Other vs. Hispanic 1.31 0.42 4.12

NH Black vs. Hispanic 2.84 1.07 7.52

NH White vs. Hispanic 3.93 1.75 8.85

Education

9th Grade or less vs. College education or more 1.64 0.72 3.70

High school graduate vs. College education or more 1.45 0.66 3.16

Income

$10,000-$25,000 vs. More than $25,000 1.05 0.37 2.98

Less than $10,000 vs. More than $25,000 1.77 0.67 4.67

Single parent

Yes vs. No 1.49 0.76 2.92

Partner smokes

Yes vs. No 1.59 0.86 2.94

Cite

Fontana/Rialto vs. L. Linda 0.76 0.28 2.04

H. Desert vs. L. Linda 1.64 0.73 3.68

S. Bernardino vs. L. Linda 0.57 0.26 1.22

Smoking at enrolment

Yes vs. No 3.17 1.44 6.95

Cigarettes

5 or less vs. Non smoker 2.17 0.84 5.62

More than 5 vs. Non smoker 4.68 1.36 16.18

Alcohol use

Yes vs. No 0.99 0.52 1.89

Drug use

Yes vs. No 1.65 0.72 3.78

Gestational age at enrolment

First trimester vs. Second trimester 4.04 1.28 12.72



Table 3. Multivariable model gestational age, age and ethnicity variables to Non Program

Completion among enrollees in the CTTP Program (San Bernardino County, California) during

2012-2013. This table illustrates Model 1: Log (Odds of program non completion) = β0 + β1 ∗

Age + β2 ∗ Whites + β3 ∗ Blacks + β4 ∗ Asian + β5 ∗ First Trimester + β6 ∗

Second Trimester

Covariates OR 95% Confidence Limits

LL UL

1st Trimester vs. 2nd

Trimester 3.87 1.15 13.04

3rd Trimester vs. 2nd

Trimester 2.87 1.43 5.77

Age 0.93 0.87 0.99

Asian/Other vs.

Hispanic 0.86 0.25 2.98

NH Black vs. Hispanic 3.13 1.13 8.69

NH White vs. Hispanic 4.38 1.87 10.25

Third trimester vs. Second trimester 2.36 1.23 4.50

Parity

2 vs. 1 0.74 0.31 1.76

3 vs. 1 0.96 0.38 2.46

4 vs. 1 0.91 0.35 2.41

5 or more vs. 1 0.74 0.30 1.84

Number of Children

1 vs. None 0.91 0.42 1.99

2 vs. None 1.04 0.43 2.53

3 or more vs. None 0.82 0.36 1.87



Table 4. Multivariable model relating smoking status at enrollments, ethnicity and age to Non

Program Completion among enrollees in the CTTP Program (San Bernardino County,

California) during 2012-2013. This table illustrates the Model

2: Log (Odds of program non completion) = β0 + β1 ∗ Age + β2 ∗ Whites + β3 ∗ Blacks +

β4 ∗ Asian + β5 ∗ Smoking At Enrollment

Covariates OR 95% Confidence Limits

LL UL

Smoking vs. Quit 2.440 1.030 5.776

Age 0.923 0.868 0.982

Asian/Other vs.

Hispanic

1.225 0.377 3.981

NH Black vs.

Hispanic

3.019 1.101 8.274

NH White vs.

Hispanic 2.949 1.236 7.036

Discussion

The program enrolled 233 participants of which 211 with the outcome variables were

used in the quantitative analysis. Figure 1. illustrates participation completion and follow up

status. Twenty-eight percent (28%) completed the 8 week program, of that, 82% at the last

follow up time had documented cessation, remained quit and did not relapse. This figure also

illustrates that 1.7 % of the participants were reported to have documented non-cessation or they

relapsed. Additionally, of those who completed the program, 16.7% were lost to follow up.

Seventy-two percent (72%) of participants did not complete the 8 week program and of that,

28% at the last time of follow up were reported to have documented cessation. Which means

those who enroll in the program regardless of completing still have goof odds of smoking

cessation.



When analyzing the characteristics of individuals who do not complete the program or

who successfully complete, the data found that Hispanics had the highest rate of completion

compared to NH Blacks and NH Whites. Research also supports these results indicating

Hispanics generally have lower maternal smoking rates, as well as smoking cessation. Research

also shows Blacks and Whites tend to have similar smoking trends in regards to smoking before

and after delivery and during pregnancy (MMWR, 2013)

Age was run as a categorical variable in the Univariable model in table 1 in order to

see the difference in age categories. Age was found to be a major predicting variable of program

non completion. Those who were older had higher prevalence of program completion, almost

having a protective effect with an OR of .33 and a CL of (.15-.75).

Gestational age was also determined to be a predicting variable for program completion.

Those in their first trimester has a 3.87 times odds of not completing the program than those in

their second trimester with a significant CL of 1.15-13.04. Those in their 3rd trimester had an

almost 3 times odds of not completing the program than those in their second trimester with and

OR of 2.87 and CL of 1.43-5.77.

Smoking at enrollment was another predicting variable that contributed to participants

completing or not completing the program. In table 3 it illustrates that those who were smoking

at enrollment compared to those who had quit have a 2.4 times odd of not completing the

program.

Limitations

The intention of the FG was to reveal some of the hidden barriers and needs of

participants. It was also intended to get a better perspectives of participants overall experience



with the program. Initially 9 participants represented from different sites were to attend, however

only 5 came, and 2 came half way into the focus group. In addition of those who attended, each

had already finished the program, whereas, the remaining 4 who didn’t attend had yet to finish

the program. This implies that results of the FG are not representative.

The Sample size of the data revealed that only 60 events happened allowing only 6

terms to be in each model. This prevents us from seeing other variables that could have attributed

to program non completion. In addition, this prevented us from testing statistical power as well

as confounders and effect modifiers.

Currently the CTTP staff does not have a standardized procedure to collect and input

data. This was noticed through observation as well as from health educator feedback. This

increased the inconsistency of data and increased the amount of missing data which intern

contributed to an even smaller sample size.

Recommendations

The CTTP program is the only comprehensive smoking cessation program that

focuses on pregnant mothers in San Bernardino County. There is a great need to expand to reach

more clientele but they only have two health educators. Receiving funding and additional grants

would allow them to bring on additional man power to reach more individuals. In addition, this

will allow staff to allocate portions of their program to develop program plans that focus merely

on individuals who are less likely to complete the program (i.e. younger participants, women in

their third and first trimester, etc.). The focus group result yielded that including family in

program especially those who smoke would serve as a benefit to their smoking cessation.

Additional funding would allow for this to happen. They would also benefit from creating mid

and end of the year evaluations in order to make appropriate adjustments in their program as



needed. Lastly, standardized procedure to collect and input data should be developed and all

former and new staff should be trained on it.

Evaluation of Field Practicum

This field practicum included and embodied many public health competencies from both global

health and epidemiology as seen in Appendix D.

i. The field practicum will be community based:

a. This field practicum took place in San Bernardino County, where it served in

many cities within the county. It provided services to outpatient and rehabilitation

homes.

ii. The field practicum will be in a cross cultural setting:

a. It served many underserved communities in cross cultural settings, serving those

in the San Bernardino County and populations of different ethnicities and

backgrounds. It allowed me to travel to different parts of the county that are

burdened with maternal smoking, and reinforced cultural sensitivity particularly

because maternal smoking for pregnant mothers can be shameful to some. This

was particularly necessary when enrolling patients into the program and

interviewing them with personal question. It was also necessary to exhibit cultural

sensitivity when creating the FG guide and having the focus group because it

would ask very personal questions which would be recorded.

iii. The field practicum will address priority public health needs of underserved

populations.



a. San Bernardino County has many underserved populations especially when it

comes to smoking cessation. Smoking has many adverse health outcomes and

San Bernardino, although not the highest rate of maternal smoking still has a high

rate of smoking compared to the state of California. Addressing this need is

imperative to not only those who smoke, but those it affects like unborn children

and second hand smokers.

iv. Assist host entity in assessing existing capacity:

a. Analyzing this data served as a baseline assessment as to what would increase the

capacity of the program. The FG also served as needs assessment as to areas of

the concerns participants had. Improvements can be made based on this.

v. Communicate lessons learned to community partners and global constituencies:

a. Apart from the field practicum objectives that needed to be met, I was able attend

meeting with important stakeholders like First 5 San Bernardino. I was also able

to attend meetings with other smoking cessation programs that were nationwide

or didn’t serve our county to learn from their programs and share ideas from what

work with ours.

vi. Implement strategies to engage marginalized and vulnerable populations in making

decisions that affect their health and well-being.

a. The data analysis revealed that there were certain populations that were less likely

to complete the program. Recommendations based on this were made on how we

can incorporate tools to have these populations included so that they can complete

the program and benefit from smoking cessation

vii. Conduct formative assessment/research:



a. This practicum was a research project which allowed me to use qualitative and

quantitative research methods.

viii. Develop monitoring and evaluation frameworks to asses program:

a. Based on the recommendations a mid and end of the year evaluation plan was

created and will be modified for the CTTP to use as needed.

Other responsibilities included attending meetings as needed, making deliveries to patients

as needed and helping with other task to help health educators. Many observations were made

while interning with the CTTP. One of the many were that the staff had a large work load, which

made it difficult for the health educators to do other work. I also noticed that the health educators

had a good relationship with all their participants and made an effort to always connect with

them in a personable way.

This field practicum was a valuable experience. I believe that it has equipped me with the

tools to be successful in the public health field. It taught me how to work well with small

institutions, how to share my ideas in a meaningful way. It also taught me how to work

efficiently independently, which is everything I need to be successful.

The school of public health was very helpful in facilitating my practicum project and they

were very helpful every step of the way. Additionally so was the organization I interned with.

They made things easier by motivating and guiding me. All in all I am grateful for the

experience.



References

Batech, Michael, Tonstad, Serena, Job, Jayakaran S., Chinnock, Richard, Oshiro, Bryan,

Merritt, T. Allen, Page, Gretchen &Singh, Pramil N. (2013). Estimating the Impact of

Smoking Cessation During Pregnancy: The San Bernardino County Experience

Center for Addiction and Mental Health (n.d) Pregnancy and Smoking: A literature review that

investigates the unique challenges that women experience during and after pregnancy.

Retrieved from http://www.pregnets.org/dl/Lit%20Review%20FINAL.pdf December,

2013

Center for Disease, Control and Prevention (2013). Smoking and Tobacco Use; Smoking

Cessation. Retrieved from

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/ December,

2013

Center for Disease, Control and Prevention. (2004) Smoking During Pregnancy---United States,

1990-2002. Morbidity Mortality Weekly Report,53(39);911-915 Retrieved from

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a1.htm), November 2013.

Cnattingius, S. (2004). The epidemiology of smoking during pregnancy: Smoking prevalence,

maternal characteristics, and pregnancy outcomes. Nicotine & Tobacco Research,

6(Suppl. 2), S125–S140. doi:10.1080/14622200410001669187.

Severson, H. H., Andrews, J. A., Lichtenstein, E., Wall, M., & Zoref, L. (1995). Predictors of

Smoking During and After Pregnancy: A Survey of Mothers of Newborns. Preventive

Medicine, 24(1), 23-28. doi: http://dx.doi.org/10.1006/pmed.1995.1004

Samet JM, Yoon SY (2001) Women and the tobacco epidemic: challenges for the 21st century.

World Health Organization, Geneva

The 2004 United States surgeon general’s report: The health consequences of smoking. (2004).

N S W Public Health Bull, 15(5–6):107.

Woodby, L. L., Windor, Richard A., Snyder Scott W., Diclemente Kohler& Carlo C.,. (1999).

Predictors of Smoking Cessation During Pregnancy. Addiction, 94(2), 10.

http://www.pregnets.org/dl/Lit%20Review%20FINAL.pdf

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a1.htm

http://dx.doi.org/10.1006/pmed.1995.1004



Appendices

Appendix A

Instrument Title: Discussion Guide: Focus Group I: CTTP Evaluation Topics

Total Participant time required: 1 hour + 30 minutes

Total focus group time: 1 hour

Break: 30 minutes

OVERALL QUESTION TO ANSWER IN FOCUS GROUP DISCUSSIONS:

The purpose of the study is to conduct evaluative research to determine

The efficacy of the CTTP

What barriers did participants encounter within the program that hindered their

success?

Which part of the program did they find most effective that attributed to their

smoking cessation?

Which part of the program did they find most ineffective that hindered their

smoking cessation?

Below is a general guide for leading our focus groups. We may modify this guide as needed.

Before the group begins, conduct the informed consent process, including compensation

discussion.

I. Introduction (10 m)

Welcome participants and introduce yourself.

Explain the general purpose of the discussion and why the participants were chosen.

Discuss the purpose and process of focus groups

Explain the presence and purpose of recording equipment and introduce observers.

Outline general ground rules and discussion guidelines such as the importance of

everyone speaking up, talking one at a time, and being prepared for the moderator to

interrupt to assure that all the topics can be covered.

Review break schedule and where the restrooms are.

Address the issue of confidentiality.

Inform the group that information discussed is going to be analyzed as a whole and that

participants' names will not be used in any analysis of the discussion.

Read a protocol summary to the participants.

Discussion Guidelines:

We would like the discussion to be informal, so there’s no need to wait for us to call on

you to respond. In fact, we encourage you to respond directly to the comments other people

make. If you don’t understand a question, please let us know. We are here to ask questions,

listen, and make sure everyone has a chance to share.



If we seem to be stuck on a topic, we may interrupt you and if you aren’t saying much, we

may call on you directly. If we do this, please don’t feel bad about it; it’s just our way of making

sure we obtain everyone’s perspective and opinion is included.

We do ask that we all keep each other’s identities, participation and remarks private. We

hope you’ll feel free to speak openly and honestly. In order to do so, each of you are assigned a

number, that has been placed on your chair. Before speaking, you each will state the number

and state what you would like to say. For example, “ I am number 10 and I think the food was

really great”

As discussed, we will be tape recording the discussion, because we don’t want to miss

any of your comments. No one outside of the CTTP will have access to these tapes and they will

be destroyed after our report is written.

Helping to assist in this focus group is Andrea and she will be taking notes and be here to assist

me if I need any help. She will also ask questions as needed

Let’s begin. Let’s find out some more about each other by going around the room one at a

time. Tell us what city do you live in and what are your favorite baby colors. I’ll start.

II. (40)

Let’s get started!

1. Initiation (enrollment and recruitment process) This is how they started the program and about how they heard of it

How long have you been in the program?

How did you find out about the program?

2. Background

When did you start smoking?

How long have you been smoking?

How long where you or are you smoking while pregnant?

What made you want to smoke?

Who else in your family smokes?

Have you tried to quit before entering this program?

If yes, why was it not successful?

Who has quit smoking while in the program?

When did you quite?

Who is still smoking?

3. Barriers (challenges and roadblocks to any component of the program)



For those of you who have not quit could you tell me why you think it has not

happened?

If you did quit but had a very hard time could you talk about some of the reason you

felt it was difficult?

What kind of assistance do you wish you had to help you to quit smoking?

What about transportation?

4. Effectiveness (Contribution of any component of the program to smoking cessation) What was most effective to them?

How much did the incentives help you to quit

Did it have a big role?

How much did the education help you to quit

Did is have a big role?

What part of the program had the biggest impact?

4 Needs improvement (improvement opportunities)

What areas of the program had the least impact on you to quit smoking?

Could you give us some ideas on how we could make the process of quitting smoking easier?

V. Closing (5 minutes)

Closing remarks

Thank the participants

Issue their compensation



Appendix B

Comprehensive Tobacco Treatment Program (CTTP)

Focus Group - Consent Form

Invitation to Participate & Purpose

You are being invited to participate in evaluating the process of Comprehensive Tobacco

Treatment Program. Thank you for taking time out of your busy schedule to consider

participation.

Voluntary Participation

Your participation in this evaluation is completely voluntary and you may withdraw your

consent to participate at any time during the process. If you choose to do so, any information

derived from your participation will be deleted from the evaluations findings.

Methods/Procedures

The methods of data collection for this evaluation will be a focus a group. The sessions will be

audio-taped, and the audio-tapes transcribed to ensure accurate reporting of the information that

you provide. No one’s name will be asked or revealed during the focus groups or individual

interviews. However, should another participant call you by name, the transcriber will be

instructed to remove all names from the transcription? No one outside of Loma Linda Medical

Center or University will have access to these tapes and they will be destroyed after our report is

written

Confidentiality

If you choose to participate, you will not be asked your name at the focus group. You will not

need to use your name in the focus groups. If by chance, you or someone you know addresses

you by name in the sessions, the transcriber will be instructed to delete all names from the

transcription. All findings used in any written reports or publications which result from this

evaluation will be reported in aggregate form with no identifying information. It is, however

useful to use direct quotes to more clearly capture the meanings in reporting the findings from

this form of evaluation.

Risks and Inconveniences

There are no anticipated physical risks to participants. Focus group members will be asked to

keep the information provided in the groups confidential.

Benefits

A potential benefit to you for participating in this evaluation for you could be having an

opportunity to describe your experience with others who have shared similar experiences.

Additionally, the opportunity to connect with other allies and share similar and divergent

experiences may help clarify and validate your experiences within this program. The benefits to

society would be based on establishing a clearer understanding of the experiences CTTP

members have and some of the obstacles and benefits of being a member of the CTTP. This

information can help the CTTP be more effective, and may provide guidance through lessons

learned.



Questions

The CTTP appreciates your participation. If you have any questions about the outcomes of this

focus group you are encouraged to email Temidayo Ogunrinu, at [email protected]

Authorization

You will be given a copy of this consent form to keep for your records. Once again, we thank

you for taking time out of your busy schedule to participate in this evaluation process.

Date: _______________________________

_____________________________________

____________________________________

Printed Name of the Participant

Signature



Appendix C

A Priori Codebook

Focus Group

TOPIC CODE FG Transcription

CTTP Participant

enrollment

process

CTTP_ENRMT_PRCSS Found out within

different sites

“..I found out through the diabetic wellness,

community hospital”

“I found out through Loma Linda Hospital

for high risk pregnancy”

“…I found out through the diabetic

program”

CTTP Participant

Smoking

Background

CTTP_PT_SMK_BKGRND Started smoking

at a young age.

Family smoked

and peer pressure

Stress kept them

smoking

All previously

stopped at one

point in their life

but started

smoking because

of stress or being

around other

smokers

“Started at age 15….and I was 4 weeks and

I haven’t had a cigarette since”

“Started when I was 15….but I am 8 weeks

when I know I am pregnant and quit”

“When I was nine I started smoking…I

smoked till I was 8 months pregnant”

CTTP smoking

status

CTTP_SMK_STATUS All completed the

8 week program

“I’ve completed the program”

“I’ve completed as well”

“I know it was a 8 week program and I

completed”

Smoking

cessation barriers

CTTP_SMK_CSS_BARR No major barriers

“Morning sickness actually helped me quit”

“Highly restricted environment helped me

to stay quit”

“Stress was a barrier”

“Transportation at certain time”



Additional Excerpts

#4: “I started when I was nine and I started smoking marijuana and I got introduced to cigarettes

and a lot of other stuff...soo”

#3: It was mainly stress, bills, under so stuff; one thing that helped me calm my nerves was to

get a pack of cigarettes and smoke, along with some alcohol.

#4: When I stopped smoking cigarettes in 2008 I had a stroke, because of my heart condition,

because of that it kind of slowed me down, just because I was kind of afraid to lose my life.

Because I have my kids, I had my two baby girls. And my two oldest ones are not from my

husband and it would be selfish If I kept doing what I was doing and lose my life and my kids

would stay by myself. But then I had my third one and she stressed me out a little. I got into a

postpartum depression. And since I am Mexican they don’t believe in depression, they just get

over it, that’s it, there is no depression here, open up your windows and walk out. I guess that

CTTP Effectives

towards smoking

cessation

CTTP_EFTVNS For participants

everything was

effective and

incentives played

a role

Convenience

“No, it was so convenient for us.”

Incentives

“I am number 6 and think that what mostly

motivated me was the diapers. Because I

have a one year and it really came in

handy”

CTTP biggest

impact toward

smoking

cessation

CTTP_BIG_IMPCT Their own

wellness and

health, being

alive and well for

their children

Pregnancy

I don’t think it I was pregnant I would still

be smoking a pack a day and drinking

Motivation

“Like I said, for me it was a big help. I had

someone to talk to”

“Because most of the time people always

say why I should quite, but this program

tells you why you should. It explains to you

and motivates you”

Education

“It just traumatized me. Seeing the man

with the hole inside his neck. The stuff I’ve

seen from the movies just traumatized me.

It makes me not even was to look at a

cigarette.”

CTTP areas of

improvement

CTTP_IMPRV Transportation to

sites and

including family

“I would say, lack of transportation”

Including family

“Yea because they(Family) smoke and just

like it teaches us it will teach them”



was my way of dealing with it was going back to smoking that was the only way that I was going

to pull myself out of there.

#3: The reason why I quit is because I didn’t want my son to come out with any complications,

asthma, and I see what the smoking done to my step daughter. And her mother did drugs when

she was pregnant and I see what it can do to a child. But I was just really concerned about my

son so I just quit cold turkey. As soon as I found out I was pregnant with my son I just quit.

M: #5 why wasn’t it successful, why didn’t you stay quit?

#5: Um, because I started hanging around the people who did it again, it was just the people in

general. I think it was more of an influence than anything else and at veronicas home we are

highly monitored, we are not allowed to smoke or drink.

#3: I don’t think it I was pregnant I would still be smoking a pack a day and drinking. I used to

have a drink everyday just to deal with life. I stopped when I got pregnant. And I can think

clearer now. I’m not drunk I don’t smoke, so pregnancy was the best thing.

#6: I am going to stay clean, but I think the thing the motivates me the most are my kids and the

fact that I am breast feeding. And I just want my kids to be healthy and they can’t be around that.

#4: Well I am breast feeding, and my husband will probably kill me if I went back to smoking

because I’m am already killing him with diapers and stuff like that for this one and my 18month

old baby.

#1: I will stay clean all the time because I know what will happen and I am breast feeding too. I

don’t think that will happen.

#5: I met Maribel in my program and they have actually helped a lot, a lot of time, the way we

say in Spanish its la maña, it’s just a custom. Your just used to having that cigarette in your hand

so as long as I have a hard candy or a mint or a snack, or beef jerky or that goody bag she offered

us, it keeps me occupied, I figured out it was me just mostly wanting to smoke, the routine of just

wanting to do it.

#6: I am number 6 and think that what mostly motivated me was the diapers. Because I have a

one year and it really came in handy. I was like whelp, I am already testing clean, and so give me

my diapers you know what I mean?

#6: It was some things that I found out and I was like whoa. I am still kind of paranoid about,

like dang, I am ok for smoking that much back then. It was a lot of information I found out that

scared me even when I was pregnant and she did the smoking Suzy with the baby inside, and my

whole pregnancy I was like I hope my baby is ok. I hope I quit soon enough you know.

M: Who is smoking Suzy?



#5: I was just mention that. Yupp, It was one of the main ways that it got to me. It actually shows

you a visual of what happens to the baby inside your stomach when your smoking a cigarette.

It’s crazy! Just the of knowing your baby can get asthma from that is crazy.

#1: Yea, Diana would say….I was in the party where they smoke a lot and I move and they come

smoke again and I was trying. So she talked to me and say “it’s your life, it’s your opportunity to

say stop smoking or go out and I am pregnant and I have baby”. She told me to do it polite how

to tell the people to stop smoking around me because I pregnant. Because I embarrassed to say

stop smoking, but Diana tell me I need to do those things.

3: I would say, lack of transportation, so something like a bus pass or a gas card if they couldn’t

make it to their appointment if you guys could provide that.

Yea because they (Family) smoke and just like it teaches us it will teach them

Appendix C

predictors of smoking cessation among pregnant women in san bernardino county

Documents