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TIPS funded by Tennessee Governor Phil Bredesen’s Office of Children’s Care Coordination
Portions of this presentation © 2002 The American College of Obstetricians and Gynecologists
A Clinician’s Guide to HelpingA Clinician’s Guide to HelpingPregnant Women Quit Smoking: Pregnant Women Quit Smoking:
Using the 5 A’sUsing the 5 A’s
Tennessee Intervention for Pregnant Smokers (TIPS)
The American College ofObstetricians and Gynecologists
Pregnancy Smoking in NE TNPregnancy Smoking in NE TN
U.S. % TN % NE TN%
Pregnancy smoking rate 12.6% 17.1% 49.0%
LBW rate 7.9% 9.4% 10.6%
Preterm birth rate 12.3% 14.1% 16.1%
2
Summary of Pregnancy Risks Associated Summary of Pregnancy Risks Associated with Smoking & Smoke Exposurewith Smoking & Smoke Exposure
• Ectopic pregnancy• Intrauterine growth
restriction• Placenta previa• Abruptio placentae• PROM• Spontaneous abortion• Preterm delivery
(Local and National Findings)
3
Postnatal Risks Associated with a Postnatal Risks Associated with a Smoke-Exposed PregnancySmoke-Exposed Pregnancy
• SIDS• Ear Infections• Asthma & Allergies• Respiratory Infections• Growth Restriction• Attention Problems• Behavioral &
Emotional Problems
(Local and National Findings)
4
Risks Associated With Secondhand Risks Associated With Secondhand Smoke ExposureSmoke Exposure
• Slowed Fetal Growth
• Higher Heart Rates (2-4wks)
• Increased Rates of: Miscarriage Preterm Delivery Low Birth Weight Conduct Problems (5-7yrs)
Effects were present even when controlling for maternal
smoking.5
Intervention Makes a Difference:Intervention Makes a Difference:Birth Outcomes Birth Outcomes
• Smoking is the most modifiable risk factor for poor birth outcomes
• Successful treatment of tobacco dependence can achieve:
– 20% reduction in low-birth-weight babies
– 17% decrease in preterm births
– 250g average birth weight increase
– Significant reduction in associated health & developmental complications
6
Intervention Makes a Difference: Intervention Makes a Difference: Smoking RatesSmoking Rates
• When compared to simple advice to quit, the use of brief interventions has more than doubled quit rates:
• Brief counseling + provision of self-help materials by a trained clinician, increases cessation rates up to 70%
7
Study UC BI
Hegaard et al., 20031 5% 14%
Windsor et al., 20002 8.8% 17.3%
Pregnancy Smoking in NE TNPregnancy Smoking in NE TN
Patients Reported: Knowing the dangers of pregnancy smoking, but
remained unwilling or unable to quit
A strong preference for individual discussions with their health care provider rather than group support sessions
That their providers did discuss smoking with them, but that these discussions did not go far enough in helping them to quit smoking
8
About TIPSAbout TIPS
• TIPS funded in January of 2007 for a 4 year period
• The project involves 2 components: 1) Service Provision (Physician-Based Brief Intervention
& Prenatal Case Management)
2) Program Evaluation
• Prospective Population Includes Pregnant Women Who Are:
– Current Smokers
– Exposed to Significant Secondhand Smoke
– Former Smokers ≤ 2 Years Smoke-Free
9
• Approximately ½ of the women will receive additional Case Management Services
• Case Managers will provide: • Additional support of smoking cessation efforts• Motivation to increase prenatal care utilization• Referrals to other needed services• Support for the reduction of life stressors including
domestic violence and depression
• Patients will also receive a TIPS Self-Help Resource Guide
• Patients will be asked to participate in research interviews10
About TIPS : Service Provision About TIPS : Service Provision
About TIPS: The ResearchAbout TIPS: The Research
• Program Evaluation Includes:• Physician Documentation of All BI Encounters• Evaluation of Medical Records• Evaluation of Delivery & Newborn Chart Information• 1-on-1 Case Manager Conducted In-depth Patient
Interviews
• Findings Used To: • Validate Provided Services• Modify and Improve Services• Conduct Cost-Benefit Analysis• Inform the Development and Implementation of the TIPS
Program on a Larger Scale11
The Physician’s Role in TIPSThe Physician’s Role in TIPS
12
5 A’s Approach 5 A’s Approach to Smoking Cessation to Smoking Cessation
• A 5-step smoking intervention proven effective for pregnant women
• Consistent with strategies developed by the National Cancer Institute, the American Medical Association, and others
• Adapted for pregnant women by ACOG
13
The 5 A’sThe 5 A’s
1. ASK about tobacco use
2. ADVISE to quit
3. ASSESS willingness to make a quit attempt
4. ASSIST in quit attempt
5. ARRANGE follow-up14
Integrating the 5 A’s into the Integrating the 5 A’s into the TIPS ProgramTIPS Program
Step 3. Document All Encounters:• ACOG/Pre-OB documentation• Physician documentation form & graph• Provides feedback to you & your patient• For Medicaid reimbursement• Provides additional data
15
Step 2. Implement the 5 A’s at EVERY visit involving a smoke-exposed pregnancy
Step 1. At INITIAL prenatal visit, ask every patient about Smoking and Smoke Exposure
PRE-OB Documentation: PRE-OB Documentation: Alternate ACOG Alternate ACOG Tobacco Use Tobacco Use QuestionsQuestions
•Located on ACOG & completed Located on ACOG & completed in the place ofin the place of traditional traditional Tobacco Tobacco
Use question #14 on Form AUse question #14 on Form A•EVERYEVERY PATIENTPATIENT is asked the alternate set of questions is asked the alternate set of questions16
17
Physician 5A’s Documentation FormPhysician 5A’s Documentation Form
ASK ASK — 1 Minute— 1 Minute
You have never smoked or have smoked fewer than 100 cigarettes in your lifetime.
You have never smoked or have smoked fewer than 100 cigarettes in your lifetime.
You stopped smoking before you found out you were pregnant and are not smoking now.
You stopped smoking before you found out you were pregnant and are not smoking now.
You stopped smoking after you found out you were pregnant and are not smoking now.
You stopped smoking after you found out you were pregnant and are not smoking now.
You smoke some now but have cut down since you found out you were pregnant.
You smoke some now but have cut down since you found out you were pregnant.
You smoke about the same amount now as you did before you found out you were pregnant.
You smoke about the same amount now as you did before you found out you were pregnant.
Which of the following statements best describes your current smoking habits?
AdviseAdviseCongratulateCongratulatePatientPatient18
ASK ASK — 1 Minute— 1 Minute
You do not have regular contact with anyone who smokes.
You do not have regular contact with anyone who smokes.
You have regular contact (but do not live) with other people who smoke, but they DO NOT smoke around you.
You have regular contact (but do not live) with other people who smoke, but they DO NOT smoke around you.
You have regular contact (but do not live) with other people who smoke, and they DO often smoke when you are around.
You have regular contact (but do not live) with other people who smoke, and they DO often smoke when you are around.
You live with at least 1 smoker, but they DO NOT smoke when you are around.
You live with at least 1 smoker, but they DO NOT smoke when you are around.
You live with at least 1 smoker, and they DO often smoke when you are around.
You live with at least 1 smoker, and they DO often smoke when you are around.
Which of the following best describes your exposure to other people smoking?
AdviseAdvise19
CongratulateCongratulatePatientPatient
ASK: ASK: DocumentationDocumentation
20
ADVISEADVISE — 1 Minute — 1 Minute
• Clear, strong, personalized advice to quit:– Clear & Strong: “As your clinician,
my best advice for you and your
baby is for you to quit
smoking and reduce your second-hand smoke exposure. I
need you to know that quitting is the most important thing you can do to protect your baby and improve your own health.”
– Personalized: Impact of smoking on the baby, the family, and the patient’s well being21
ADVISEADVISE: : DocumentationDocumentation
22
ASSESSASSESS — 1 Minute — 1 Minute
• Assess the patient’s willingness to quit within the next 30 days.
• If a patient responds that she would like to try to quit within the next 30 days, move on to the Assist step.
• If the patient does not want to try to quit, try to increase her motivation via education and personalizing the issue.
23
ASSESS ASSESS — 1 Minute — 1 Minute
I---------I----------I----------I----------I---------I----------I----------I---------I----------I----------I
0 1 2 3 4 5 6 7 8 9 10
Not At All Moderately ExtremelyWilling Willing Willing
ASK: “How WILLING are you to quit smoking in the next 30 days?”
ASK:
“What would it take to make you more willing to quit, to get you to move from your score to a score 3 pts higher on the scale?”
24
ASSESS: ASSESS: DocumentationDocumentation
25
• Addiction has both PHYSICAL & BEHAVIORAL components
• Both factors must be addressed for successful cessation
• ASSIST techniques should be chosen in accordance with patient’s willingness to quit
ASSIST ASSIST — 3+ Minutes— 3+ Minutes
Initial Considerations
26
Remove all tobacco products from her home Identify triggers & roadblocks Determine what she can do in situations in
which she usually smokes Develop approaches to manage withdrawal
symptoms Plan ways to handle others smoking
around her
Basic Strategies Some Women Basic Strategies Some Women Find HelpfulFind Helpful
27
Basic Strategies Some Women Find Basic Strategies Some Women Find Helpful – cont.Helpful – cont.
Discuss the dangers of secondhand smoke Identify & arrange social support Complete quit date contract
28
Specific Methods of AssistingSpecific Methods of Assisting
Provide Pregnancy-Specific Smoking Cessation Self-Help Materials:
• Health Hazards For The Baby• Health Benefits Timeline• Identify Personal Barriers
& Potential Triggers• Patient Identified Personal
Benefits To Quitting• Withdrawal Symptoms:
Cravings And Coping Skills• Cost Savings & Suggest Personal
Rewards• Alternative Ways to Cope
& Manage Stress29
• Have you ever heard: ““I smoked with my first child and s/he was OK!”I smoked with my first child and s/he was OK!” ““My mom smoked with me and I turned out OK!”My mom smoked with me and I turned out OK!”
• Talk with your patient about varying susceptibility• Circumstances that vary between pregnancies may
significantly impact the degree to which the fetus will be harmed by smoking:
– Overall amount of primary & secondary smoke exposure– Stress– Nutrition– Increased age during pregnancy– Environmental factors– Overall health30
Additional Assist Components: Additional Assist Components: Addressing Varying SusceptibilityAddressing Varying Susceptibility
Additional Assist Components: Additional Assist Components: Pharmacologic InterventionPharmacologic Intervention
• Behavioral intervention is the first-line treatment for pregnant women
• Pharmacotherapy can be considered for heavy smokers unable to quit via behavioral interventions alone
• Very limited data on the safety or effectiveness of pharmacologic treatments in pregnant women
31
Additional Assist Components: Additional Assist Components: Pharmacologic InterventionPharmacologic Intervention
• If used: An intermittent delivery system should be used Administered at lowest effective range Recommended that blood levels of nicotine should be
monitored
• Pharmacotherapy is a safe alternative for family members to decrease secondhand smoke exposure
32
Class CClass C• Nicotine polacrilex
gum, lozenges
• Varenicline (Chantix)
• Bupropion extended release (Zyban, Wellbutrin)
• Clonidine
Class DClass D• Nicotine transdermal
patches
• Nicotine nasal spray
• Nicotine vapor inhaler
• Nortriptyline
Additional Assist Components: Additional Assist Components: Pharmacologic InterventionPharmacologic Intervention
33
ASSIST: ASSIST: DocumentationDocumentation
34
ARRANGEARRANGE — 1+ Minute — 1+ Minute
• Follow up to monitor progress and provide support• Encourage the patient• Ask about concerns or difficulties• Invite her to talk about her successes• Express willingness to help• Offer referrals to the Smoking Quit Lines, local
Health Departments, your TIPS Case Manager, etc.
35
ARRANGE for a Follow-Up: Documentation
Additional Sections of TIPS Documentation Form
36
Reimbursement CodingReimbursement Coding
• ICD-9-CM code 305.1 (tobacco use disorder, tobacco dependence)
AND
• CPT code 99401 (15-minute physician-provided counseling)– with modifier 25 as part of regular prenatal visit
OR
• CPT code 99211 (nurse counseling)37
38
Step 5. Provide TIPS Smoking Cessation Guide To All OB Patients In Above Categories
Summary of Tasks for TIPS Summary of Tasks for TIPS Program – cont.Program – cont.
39
Step 4. Refer Any of the Following Patients to your TIPS Case Manager:
Current Smoker Anyone Regularly Exposed to Second Hand
Smoke Former Smoker ≤ 2 Years Smoke-Free
Sample Contents: Sample Contents: What Is In A CigaretteWhat Is In A Cigarette
• One Cigarette Contains Over 4,000 Chemicals! • The Overwhelming Majority of These Chemicals Have Been Shown to be Carcinogenic!
Some Of The Over 4,000 Chemicals In A Cigarette
AcroleinToxic Liquid with Cancerous Vapors
HexamineBarbecue Lighter
CadmiumRechargeable Batteries
Nitrous Oxide PhenolsDisinfectant
AcetoneNail Polish Remover
Hydrogen CyanideGas Chamber Poison
PyridyneWater Repellents, Bactericides, &Herbicides
PropionaldehydeChemical Disinfectant, PreservativePlastic , & Rubber
Acetic AcidVinegar
MethanolAntifreeze & Rocket Fuel
DDT/DieldrinInsecticides & Bug Sprays
Carbon MonoxideCar Exhaust Fumes
AmmoniaFloor/Toilet Cleaner
NapthaleneMothballs
EthanolAlcohol
Stearic AcidCandle Wax & Fireworks
ArsenicPoison used in Making Insecticides
NicotineInsecticide/ Addictive Drug
FormaldehydePreserver-BodyTissue & Fabric
TolueneIndustrial Solvent
ButaneCigarette Lighter Fluid
NitrobenzeneGasoline Additive
Formic AcidGas Used in Making Pesticides & Textiles
Vinyl ChlorideMakes PVC
40
Sample Contents: Sample Contents: Timing of Health BenefitsTiming of Health Benefits
1990 Surgeon General’s Report
20 minutesBlood pressure, heart rate return to
normal
8 hoursO2 level returns to normal; nicotine
and CO levels reduced by half
24 hoursCO is eliminated from body; lungs begin to eliminate mucus, debris
48 hoursNicotine eliminated from body; taste
and smell improve
72 hoursBreathing is easier; bronchial tubes
relax; energy levels increase
2 to 12 weeksCirculation improves
3 to 9 monthsLung function increases by up to
10%; coughing, wheezing, breathing problems reduced
1 yearHeart attack risk halved
10 yearsLung cancer risk halved
15 yearsHeart attack risk same as for someone who never smoked
41
Sample Contents: Sample Contents: Health Benefits for Both Mother & ChildHealth Benefits for Both Mother & Child
THE BABY’S HEALTHTHE BABY’S HEALTH
If She Quits While Pregnant, Her Baby Will:• Get more oxygen.• Be protected from deadly carbon
monoxide and other carcinogens• Have fewer health problems such
as asthma, wheezing, colds, ear infections, etc.
• Be more likely to be born at a healthy size and weight.
• Cough and cry less.• Be less likely to develop chronic
lifelong disabilities• Have fewer doctor visits.• Likely have fewer behavioral or
attention problems later in life.• Be less likely to die of prenatal
complications & SIDS .
THE PATIENT’S HEALTHTHE PATIENT’S HEALTH
If She Quits Smoking, She Will:• Breathe easier & have more
energy.• Be less likely to have a
miscarriage, stillbirth or spontaneous abortion.
• Decrease her chances of having a heart attack, stroke, heart disease, and lung cancer.
• Be a good role model for her child.• Have fewer wrinkles.• Have clothes, a car, a home, and
breath that smell better.• Save money that can be spent on
other things.• Enjoy the smell and taste of food
again.• Feel great about quitting.42
Sample Contents: Sample Contents: Potential Cost SavingsPotential Cost Savings
43
Tennessee Intervention for Pregnant SmokersTennessee Intervention for Pregnant Smokers
East Tennessee State UniversityBox 70621 Johnson City, TN 37614
Office: (423) 439- 6705 Fax: (423) 439-2440Beth Bailey, Ph.D., Program Director: [email protected]
Laura K. Jones Cole, M.S., M.A., Program Coordinator: [email protected] Website: http://www.etsu.edu/tips
Step 6. Contact TIPS Staff With Questions/Concerns
Summary of Tasks for TIPS Summary of Tasks for TIPS Program – cont.Program – cont.
44
ResourcesResources
• American College of Obstetricians and Gynecologists (www.acog.org)
• TIPS Online (www.etsu.edu/TIPS)
• Smoke-Free Families (www.smokefreefamilies.org)
• Treating Tobacco Use and Dependence
• Agency for Healthcare Research and Quality (www.ahrq.gov)
1. Hegaard HK, Kjaergaard H, Moller LF, Wachmann H, Ottesen B. Multimodal intervention raises smoking cessation rates during pregnancy. Acta Obstet Gynecol Scand, 2003;82:813-9.
2. Windsor RA, Woodby LL, Miller TM, Hardin JM, Crawford MA, DiClemente CC. Effectiveness of Agency for Health Care Policy and Research clinical practice guidelines and patent education methods for pregnant smokers in Medicaid maternity care. Am J Obstet Gynecol, 200;1:1.
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