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Physician Training PowerPoint Presentation

  1. 1. A Clinician’s Guide to Helping Pregnant Women Quit Smoking: Using the 5 A’s Tennessee Intervention for Pregnant Smokers (TIPS) The American College of Obstetricians and Gynecologists 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
  2. 2. Pregnancy 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%
  3. 3. Summary of Pregnancy Risks Associated with Smoking & Smoke Exposure <ul><li>Ectopic pregnancy </li></ul><ul><li>Intrauterine growth restriction </li></ul><ul><li>Placenta previa </li></ul><ul><li>Abruptio placentae </li></ul><ul><li>PROM </li></ul><ul><li>Spontaneous abortion </li></ul><ul><li>Preterm delivery </li></ul>(Local and National Findings)
  4. 4. Postnatal Risks Associated with a Smoke-Exposed Pregnancy <ul><li>SIDS </li></ul><ul><li>Ear Infections </li></ul><ul><li>Asthma & Allergies </li></ul><ul><li>Respiratory Infections </li></ul><ul><li>Growth Restriction </li></ul><ul><li>Attention Problems </li></ul><ul><li>Behavioral & Emotional Problems </li></ul>(Local and National Findings)
  5. 5. Risks Associated With Secondhand Smoke Exposure <ul><li>Slowed Fetal Growth </li></ul><ul><li>Higher Heart Rates (2-4wks) </li></ul><ul><li>Increased Rates of: </li></ul><ul><ul><ul><li>Miscarriage </li></ul></ul></ul><ul><ul><ul><li>Preterm Delivery </li></ul></ul></ul><ul><ul><ul><li>Low Birth Weight </li></ul></ul></ul><ul><ul><ul><li>Conduct Problems (5-7yrs) </li></ul></ul></ul>Effects were present even when controlling for maternal smoking.
  6. 6. Intervention Makes a Difference: Birth Outcomes <ul><li>Smoking is the most modifiable risk factor for poor birth outcomes </li></ul><ul><li>Successful treatment of tobacco dependence can achieve: </li></ul><ul><ul><li>20% reduction in low-birth-weight babies </li></ul></ul><ul><ul><li>17% decrease in preterm births </li></ul></ul><ul><ul><li>250g average birth weight increase </li></ul></ul><ul><ul><li>Significant reduction in associated health & developmental complications </li></ul></ul>
  7. 7. Intervention Makes a Difference: Smoking Rates <ul><li>When compared to simple advice to quit, the use of brief interventions has more than doubled quit rates: </li></ul><ul><li>Brief counseling + provision of self-help materials by a trained clinician , increases cessation rates up to 70% </li></ul>Study UC BI Hegaard et al., 2003 1 5% 14% Windsor et al., 2000 2 8.8% 17.3%
  8. 8. Pregnancy Smoking in NE TN <ul><li>Patients Reported: </li></ul><ul><ul><li>Knowing the dangers of pregnancy smoking, but remained unwilling or unable to quit </li></ul></ul><ul><ul><li>A strong preference for individual discussions with their health care provider rather than group support sessions </li></ul></ul><ul><ul><li>That their providers did discuss smoking with them, but that these discussions did not go far enough in helping them to quit smoking </li></ul></ul>
  9. 9. About TIPS <ul><li>TIPS funded in January of 2007 for a 4 year period </li></ul><ul><li>The project involves 2 components: </li></ul><ul><ul><ul><li>Service Provision (Physician-Based Brief Intervention & Prenatal Case Management) </li></ul></ul></ul><ul><ul><ul><li>Program Evaluation </li></ul></ul></ul><ul><li>Prospective Population Includes Pregnant Women Who Are: </li></ul><ul><ul><ul><ul><li>Current Smokers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Exposed to Significant Secondhand Smoke </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Former Smokers ≤ 2 Years Smoke-Free </li></ul></ul></ul></ul>
  10. 10. <ul><li>Approximately ½ of the women will receive additional Case Management Services </li></ul><ul><li>Case Managers will provide: </li></ul><ul><ul><ul><li>Additional support of smoking cessation efforts </li></ul></ul></ul><ul><ul><ul><li>Motivation to increase prenatal care utilization </li></ul></ul></ul><ul><ul><ul><li>Referrals to other needed services </li></ul></ul></ul><ul><ul><ul><li>Support for the reduction of life stressors including domestic violence and depression </li></ul></ul></ul><ul><li>Patients will also receive a TIPS Self-Help Resource Guide </li></ul><ul><li>Patients will be asked to participate in research interviews </li></ul>About TIPS : Service Provision
  11. 11. About TIPS: The Research <ul><li>Program Evaluation Includes: </li></ul><ul><ul><ul><li>Physician Documentation of All BI Encounters </li></ul></ul></ul><ul><ul><ul><li>Evaluation of Medical Records </li></ul></ul></ul><ul><ul><ul><li>Evaluation of Delivery & Newborn Chart Information </li></ul></ul></ul><ul><ul><ul><li>1-on-1 Case Manager Conducted In-depth Patient Interviews </li></ul></ul></ul><ul><li>Findings Used To: </li></ul><ul><ul><ul><li>Validate Provided Services </li></ul></ul></ul><ul><ul><ul><li>Modify and Improve Services </li></ul></ul></ul><ul><ul><ul><li>Conduct Cost-Benefit Analysis </li></ul></ul></ul><ul><ul><ul><li>Inform the Development and Implementation of the TIPS Program on a Larger Scale </li></ul></ul></ul>
  12. 12. The Physician’s Role in TIPS
  13. 13. 5 A’s Approach to Smoking Cessation <ul><li>A 5-step smoking intervention proven effective for pregnant women </li></ul><ul><li>Consistent with strategies developed by the National Cancer Institute, the American Medical Association, and others </li></ul><ul><li>Adapted for pregnant women by ACOG </li></ul>
  14. 14. The 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-up
  15. 15. Integrating the 5 A’s into the TIPS Program <ul><li>Step 3. Document All Encounters: </li></ul><ul><ul><ul><ul><li>ACOG/Pre-OB documentation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physician documentation form & graph </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Provides feedback to you & your patient </li></ul></ul></ul></ul><ul><ul><ul><ul><li>For Medicaid reimbursement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Provides additional data </li></ul></ul></ul></ul>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
  16. 16. PRE-OB Documentation: Alternate ACOG Tobacco Use Questions <ul><li>Located on ACOG & completed in the place of traditional Tobacco </li></ul><ul><li>Use question #14 on Form A </li></ul><ul><li>EVERY PATIENT is asked the alternate set of questions </li></ul>
  17. 17. Physician 5A’s Documentation Form
  18. 18. ASK — 1 Minute 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 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 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? Advise Congratulate Patient
  19. 19. ASK — 1 Minute 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, 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, and they DO often smoke when you are around. Which of the following best describes your exposure to other people smoking? Advise Congratulate Patient
  20. 20. ASK: Documentation
  21. 21. ADVISE — 1 Minute <ul><li>Clear, strong, personalized advice to quit: </li></ul><ul><ul><li>Clear & Strong: “As your clinician, </li></ul></ul><ul><ul><li>my best advice for you and your </li></ul></ul><ul><ul><li>baby is for you to quit </li></ul></ul><ul><ul><li>smoking and reduce your second-hand smoke exposure. I </li></ul></ul><ul><ul><li>need you to know that quitting is the most important thing you can do to protect your baby and improve your own health.” </li></ul></ul><ul><ul><li>Personalized: Impact of smoking on the baby, the family, and the patient’s well being </li></ul></ul>
  22. 22. ADVISE : Documentation
  23. 23. ASSESS — 1 Minute <ul><li>Assess the patient’s willingness to quit within the next 30 days. </li></ul><ul><li>If a patient responds that she would like to try to quit within the next 30 days, move on to the Assist step. </li></ul><ul><li>If the patient does not want to try to quit, try to increase her motivation via education and personalizing the issue. </li></ul>
  24. 24. ASSESS — 1 Minute <ul><li>I---------I----------I----------I----------I---------I----------I----------I---------I----------I----------I </li></ul><ul><li>0 1 2 3 4 5 6 7 8 9 10 </li></ul><ul><li>Not At All Moderately Extremely </li></ul><ul><li>Willing Willing Willing </li></ul>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?”
  25. 25. ASSESS: Documentation
  26. 26. <ul><li>Addiction has both PHYSICAL & BEHAVIORAL components </li></ul><ul><li>Both factors must be addressed for successful cessation </li></ul><ul><li>ASSIST techniques should be chosen in accordance with patient’s willingness to quit </li></ul>ASSIST — 3+ Minutes Initial Considerations
  27. 27. <ul><li>Remove all tobacco products from her home </li></ul><ul><li>Identify triggers & roadblocks </li></ul><ul><li>Determine what she can do in situations in which she usually smokes </li></ul><ul><li>Develop approaches to manage withdrawal symptoms </li></ul><ul><li>Plan ways to handle others smoking around her </li></ul>Basic Strategies Some Women Find Helpful
  28. 28. Basic Strategies Some Women Find Helpful – cont. <ul><li>Discuss the dangers of secondhand smoke </li></ul><ul><li>Identify & arrange social support </li></ul><ul><li>Complete quit date contract </li></ul>
  29. 29. Specific Methods of Assisting <ul><li>Provide Pregnancy-Specific Smoking Cessation Self-Help Materials : </li></ul><ul><ul><ul><li>Health Hazards For The Baby </li></ul></ul></ul><ul><ul><ul><li>Health Benefits Timeline </li></ul></ul></ul><ul><ul><ul><li>Identify Personal Barriers & Potential Triggers </li></ul></ul></ul><ul><ul><ul><li>Patient Identified Personal Benefits To Quitting </li></ul></ul></ul><ul><ul><ul><li>Withdrawal Symptoms: Cravings And Coping Skills </li></ul></ul></ul><ul><ul><ul><li>Cost Savings & Suggest Personal Rewards </li></ul></ul></ul><ul><ul><ul><li>Alternative Ways to Cope & Manage Stress </li></ul></ul></ul>
  30. 30. <ul><li>Have you ever heard: </li></ul><ul><ul><ul><li>“ I smoked with my first child and s/he was OK!” </li></ul></ul></ul><ul><ul><ul><li>“ My mom smoked with me and I turned out OK!” </li></ul></ul></ul><ul><li>Talk with your patient about varying susceptibility </li></ul><ul><li>Circumstances that vary between pregnancies may significantly impact the degree to which the fetus will be harmed by smoking: </li></ul><ul><ul><ul><li>Overall amount of primary & secondary smoke exposure </li></ul></ul></ul><ul><ul><ul><li>Stress </li></ul></ul></ul><ul><ul><ul><li>Nutrition </li></ul></ul></ul><ul><ul><ul><li>Increased age during pregnancy </li></ul></ul></ul><ul><ul><ul><li>Environmental factors </li></ul></ul></ul><ul><ul><ul><li>Overall health </li></ul></ul></ul>Additional Assist Components: Addressing Varying Susceptibility
  31. 31. Additional Assist Components: Pharmacologic Intervention <ul><li>Behavioral intervention is the first-line treatment for pregnant women </li></ul><ul><li>Pharmacotherapy can be considered for heavy smokers unable to quit via behavioral interventions alone </li></ul><ul><li>Very limited data on the safety or effectiveness of pharmacologic treatments in pregnant women </li></ul>
  32. 32. Additional Assist Components: Pharmacologic Intervention <ul><li>If used : </li></ul><ul><ul><li>An intermittent delivery system should be used </li></ul></ul><ul><ul><li>Administered at lowest effective range </li></ul></ul><ul><ul><li>Recommended that blood levels of nicotine should be monitored </li></ul></ul><ul><li>Pharmacotherapy is a safe alternative for family members to decrease secondhand smoke exposure </li></ul>
  33. 33. <ul><li>Class C </li></ul><ul><li>Nicotine polacrilex gum, lozenges </li></ul><ul><li>Varenicline (Chantix) </li></ul><ul><li>Bupropion extended release (Zyban, Wellbutrin) </li></ul><ul><li>Clonidine </li></ul>Additional Assist Components: Pharmacologic Intervention <ul><li>Class D </li></ul><ul><li>Nicotine transdermal patches </li></ul><ul><li>Nicotine nasal spray </li></ul><ul><li>Nicotine vapor inhaler </li></ul><ul><li>Nortriptyline </li></ul>
  34. 34. ASSIST: Documentation
  35. 35. ARRANGE — 1+ Minute <ul><li>Follow up to monitor progress and provide support </li></ul><ul><li>Encourage the patient </li></ul><ul><li>Ask about concerns or difficulties </li></ul><ul><li>Invite her to talk about her successes </li></ul><ul><li>Express willingness to help </li></ul><ul><li>Offer referrals to the Smoking Quit Lines, local Health Departments, your TIPS Case Manager, etc. </li></ul>ARRANGE for a Follow-Up: Documentation
  36. 36. Additional Sections of TIPS Documentation Form
  37. 37. Reimbursement Coding <ul><li>ICD-9-CM code 305.1 (tobacco use disorder, tobacco dependence) </li></ul><ul><li>AND </li></ul><ul><li>CPT code 99401 (15-minute physician-provided counseling) </li></ul><ul><ul><li>with modifier 25 as part of regular prenatal visit </li></ul></ul><ul><li>OR </li></ul><ul><li>CPT code 99211 (nurse counseling) </li></ul>
  38. 38.
  39. 39. Summary of Tasks for TIPS Program – cont. Step 5. Provide TIPS Smoking Cessation Guide To All OB Patients In Above Categories <ul><li>Step 4. Refer Any of the Following Patients to your </li></ul><ul><li> TIPS Case Manager: </li></ul><ul><ul><ul><ul><li>Current Smoker </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anyone Regularly Exposed to Second Hand Smoke </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Former Smoker ≤ 2 Years Smoke-Free </li></ul></ul></ul></ul>
  40. 40. Sample Contents: What Is In A Cigarette <ul><li>One Cigarette Contains Over 4,000 Chemicals! </li></ul><ul><li>The Overwhelming Majority of These Chemicals Have Been Shown to be Carcinogenic! </li></ul><ul><li>Some Of The Over 4,000 Chemicals In A Cigarette </li></ul>Acrolein Toxic Liquid with Cancerous Vapors Hexamine Barbecue Lighter Cadmium Rechargeable Batteries Nitrous Oxide Phenols Disinfectant Acetone Nail Polish Remover Hydrogen Cyanide Gas Chamber Poison Pyridyne Water Repellents, Bactericides, & Herbicides Propionaldehyde Chemical Disinfectant, Preservative Plastic , & Rubber Acetic Acid Vinegar Methanol Antifreeze & Rocket Fuel DDT/Dieldrin Insecticides & Bug Sprays Carbon Monoxide Car Exhaust Fumes Ammonia Floor/Toilet Cleaner Napthalene Mothballs Ethanol Alcohol Stearic Acid Candle Wax & Fireworks Arsenic Poison used in Making Insecticides Nicotine Insecticide/ Addictive Drug Formaldehyde Preserver-Body Tissue & Fabric Toluene Industrial Solvent Butane Cigarette Lighter Fluid Nitrobenzene Gasoline Additive Formic Acid Gas Used in Making Pesticides & Textiles Vinyl Chloride Makes PVC
  41. 41. Sample Contents: Timing of Health Benefits 1990 Surgeon General’s Report 20 minutes Blood pressure, heart rate return to normal 8 hours O 2 level returns to normal; nicotine and CO levels reduced by half 24 hours CO is eliminated from body; lungs begin to eliminate mucus, debris 48 hours Nicotine eliminated from body; taste and smell improve 72 hours Breathing is easier; bronchial tubes relax; energy levels increase 2 to 12 weeks Circulation improves 3 to 9 months Lung function increases by up to 10%; coughing, wheezing, breathing problems reduced 1 year Heart attack risk halved 10 years Lung cancer risk halved 15 years Heart attack risk same as for someone who never smoked
  42. 42. Sample Contents: Health Benefits for Both Mother & Child <ul><li>THE BABY’S HEALTH </li></ul><ul><li>If She Quits While Pregnant, </li></ul><ul><li>Her Baby Will : </li></ul><ul><li>Get more oxygen. </li></ul><ul><li>Be protected from deadly carbon monoxide and other carcinogens </li></ul><ul><li>Have fewer health problems such as asthma, wheezing, colds, ear infections, etc. </li></ul><ul><li>Be more likely to be born at a healthy size and weight. </li></ul><ul><li>Cough and cry less. </li></ul><ul><li>Be less likely to develop chronic lifelong disabilities </li></ul><ul><li>Have fewer doctor visits. </li></ul><ul><li>Likely have fewer behavioral or attention problems later in life. </li></ul><ul><li>Be less likely to die of prenatal complications & SIDS . </li></ul><ul><li>THE PATIENT’S HEALTH </li></ul><ul><li>If She Quits Smoking, She Will: </li></ul><ul><li>Breathe easier & have more energy. </li></ul><ul><li>Be less likely to have a miscarriage, stillbirth or spontaneous abortion. </li></ul><ul><li>Decrease her chances of having a heart attack, stroke, heart disease, and lung cancer. </li></ul><ul><li>Be a good role model for her child. </li></ul><ul><li>Have fewer wrinkles. </li></ul><ul><li>Have clothes, a car, a home, and breath that smell better. </li></ul><ul><li>Save money that can be spent on other things. </li></ul><ul><li>Enjoy the smell and taste of food again. </li></ul><ul><li>Feel great about quitting. </li></ul>
  43. 43. Sample Contents: Potential Cost Savings
  44. 44. Summary of Tasks for TIPS Program – cont. Tennessee Intervention for Pregnant Smokers East Tennessee State University Box 70621 Johnson City, TN 37614 Office: (423) 439- 6705 Fax: (423) 439-2440 Beth Bailey, Ph.D., Program Director: [email_address] Laura K. Jones Cole, M.S., M.A., Program Coordinator: [email_address] TIPS Website: Step 6. Contact TIPS Staff With Questions/Concerns
  45. 45. Resources <ul><li>American College of Obstetricians and Gynecologists ( </li></ul><ul><li>TIPS Online ( ) </li></ul><ul><li>Smoke-Free Families ( </li></ul><ul><li>Treating Tobacco Use and Dependence </li></ul><ul><li>Agency for Healthcare Research and Quality ( ) </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
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