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%

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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)

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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)

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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

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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%

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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

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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

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• 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

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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

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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

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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

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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

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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

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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.

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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?”

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ASSESS: ASSESS: DocumentationDocumentation

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• 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

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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

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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

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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

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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

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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

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ASSIST: ASSIST: DocumentationDocumentation

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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.

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ARRANGE for a Follow-Up: Documentation

Additional Sections of TIPS Documentation Form

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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

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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.

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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

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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

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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

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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: nordstro@etsu.edu

Laura K. Jones Cole, M.S., M.A., Program Coordinator: colelj@etsu.eduTIPS 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.

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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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