Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data from the First Two Years of TIPS Beth A. Bailey, PhD Associate Professor of Family Medicine

Pregnancy Smoking Intervention in Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data NE Tennessee: Effectiveness Data from the First Two Years of TIPSfrom the First Two Years of TIPS

Beth A. Bailey, PhDAssociate Professor of Family Medicine

Director, Tennessee Intervention for Pregnant Smokers

East Tennessee State University

Overview of Today’s SessionOverview of Today’s Session Describe the TIPS program and its effectiveness in the first

two years Specifically, describe the changes in pregnancy smoking

behavior of participating women Also, examine characteristics of the program that predict

smoking reduction, cessation, and quit attempts Finally, examine the association between pregnancy

smoking status, change in status, and birth outcomes

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BackgroundBackground

• Rates of pregnancy smoking have been declining in the United States – decrease of 42% in the last 15 years

• Nationally, 11% of pregnant women smoke during pregnancy

• Rates are significantly higher in many regions of the country and within certain population groups

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• The statewide rate of pregnancy smoking in Tennessee is 17%, the third highest rate in the nation

• In Northeast Tennessee, rates of pregnancy smoking range from 25-43%* - more than double the state average and as much as quadruple that of the national average

• Rates are higher among Caucasian women, those receiving government assistance, and those living in the most rural areas

* Data source–delivery chart reviews in Washington, Carter, & Sullivan Co hospitals4


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Hospital 2006 2007 Change

JCMC 31.4% 33.0% ↑1.6%

JCSH 14.5% 17.1% ↑2.6%

Indian Path* 29.7% 37.5% ↑7.8%

Sycamore Shoals 42.5% 37.6% ↓4.9%

Local Pregnancy Smoking Rates by Delivery Hospital and Year


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EFFECTS ARE SEEN DURING:EFFECTS ARE SEEN DURING:

SMOKING SMOKING NEGATIVELY NEGATIVELY AFFECTS:AFFECTS:


• Ectopic pregnancy• Intrauterine growth

restriction• Placenta previa• Placental abruption• PROM• Miscarriage• Preterm delivery

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BackgroundBackground• National studies have reported links

between pregnancy smoking and poor birth outcomes

• Our local findings indicate*:– Compared with those born to non-

smokers, newborns of smokers were nearly 350gm lighter, 1 inch shorter, and were born almost 1 week earlier

– Babies born to smokers were nearly twice as likely to be classified as low birth weight, to be born preterm, and to be admitted to the NICU

8 * Bailey BA, Jones Cole LK. Rurality and birth outcomes: Findings from Southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health, 25(2), 141-149, 2009.

BackgroundBackground• We have also demonstrated the relative impact of smoking in

relation to birth outcomes locally*• Compared with other modifiable health behaviors, including

nutrition, adequacy of prenatal care utilization, and the use of alcohol and illicit drugs, pregnancy smoking was the strongest predictor of a low birth weight delivery

9* Bailey B, Byrom A. Factors predicting birth weight in a low-risk sample: The role of modifiable pregnancy health behaviors. Maternal Child Health Journal, 11, 173-179, 2007.


• SIDS• Ear infections• Asthma & allergies• Respiratory infections• Growth restriction• Cognitive delays and

deficits• Behavioral &

emotional problems

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• 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 11


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• Other findings and recommendations:– Interventions need to be culturally appropriate –

what works in one setting may not work in another; particular issue in setting where smoking is more acceptable

– Interventions need to address issues beyond just smoking that may impede efforts to quit including mental health, social support, stress, practical needs, and IPV

– Address potential relapse post-partum

Interviews with Local Prenatal Smokers Revealed:A strong preference for individual

discussions with their health care provider rather than group support sessions

Knowing the dangers of pregnancy smoking, but were still unable or unwilling to quit

That their providers did discuss smoking with them, but that these discussions did not go far enough in helping them to quit smoking13


BackgroundBackground• Until recently, little had been achieved in the way of

organized efforts to address pregnancy smoking in Northeast Tennessee

• In January of 2007 Governor Bredesen’s office strengthened efforts to improve birth outcomes in this region and funded the Tennessee Intervention for Pregnant Smokers (TIPS) program for a 4-year period

• TIPS is a multi-faceted approach that aims to reduce pregnancy smoking rates and improve birth outcomes in 6 counties throughout NE TN

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$

$

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Description of TIPSDescription of TIPSThe program involves:

1) Physician training in providing smoking cessation counseling as a routine part of prenatal care

2) Nurse training in providing smoking cessation counseling during prenatal care & inpatient services

3) Provision of prenatal case management services in practices4) Provision of a hospital-based case manager for admitted high-risk women

and those post-partum 5) Education and training programs for nursing students6) Community-based information and education, including cessation

workshops7) Development and provision of self-help materials8) Web page with educational information for providers and patients9) Research opportunities for students10)Program Evaluation

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• Prospective population includes pregnant women in the 6-county NE TN region who are:

• Current smokers• Exposed to significant second hand smoke• Former smokers ≤ 2 years smoke-free

• All eligible women are:• Provided 5 A’s counseling by their prenatal care provider• Given a TIPS self-help manual • Asked to participate in research interviews

• Case Managers provide: • Smoking cessation counseling & support• Motivation to increase prenatal care utilization• Referrals to other needed services• Support for increasing social support and reducing life

stressors including domestic violence and depression 16

Description of TIPSDescription of TIPS

TIPS Progress & Findings to DateTIPS Progress & Findings to Date

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• Two full-time Case Managers see patients at two area OB practices with high rates of pregnancy smoking

• An additional full-time Case Manager provides on-call services for patients from other practices who qualify for the project and are interested in meeting with a case manager; this case manager also provides services to pregnant inpatients at area hospitals


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• At the end of Year 2 (March 2009), 1054 eligible women had been enrolled in the TIPS program

• Eligible women represented about 50% of prenatal patients at Case Manager practices

• Only 8% of eligible women declined to participate at some level

• Of the 1054, 688 had delivered by the end of Year 2 and are included in this report


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Of the participants who entered prenatal care as smokers (N=420, 61%): 20% had a least one quit attempt

Smoking Status at Delivery*:

ContinuedSmokingSignificantReductionQuit Completely51%

41%

8%

* Data from multiple modes of self-report and biochemical verification


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Of the participants with significant second hand smoke exposure

Second Hand Smoke Exposure Status at Delivery:

ContinuedExposureSignificantReductionEliminatedCompletely47%

26%17%


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Of the participants who quit smoking just prior to conception, or after learning they were pregnant (but before entry into prenatal care):

90% remained smoke-free

throughout pregnancy


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• What aspects of TIPS program participation were associated with smoking/smoke exposure reduction and cessation?

• Looked at many aspects of participation including number and timing of visits with a CM, and the type of information and assistance provided in those sessions


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Reduced Smoking

Quit Smoking

Attempted to Quit Smoking

All Participants 51% 8% 20%

CM mtg 1st trimester 52% 8% 16%

2+ CM mtgs 55% 9% 28%

4+ CM mtgs 50% 20% 35%

2+ 5 A’s sessions 49% 8% 26%

In-depth counseling 92% 0% 21%


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Reduced Smoking

Quit Smoking



Used TIPS book 44% 10% 19%

Info: stress reduction 71% 4% 13%

Info: mental health 59% 6% 35%

Info: relapse prevention

71% 5% 23%

Info: cessation for others

62% 8% 24%


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Reduced Smoking

Quit Smoking



Assistance with practical issues

60% 7% 21%

Any outside referral 63% 11% 29%

Referral: outside counseling

61% 11% 34%

Referral: partner to HD

53% 12% 19%


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Continued Smoking

Reduced Smoking

Quit Smoking

Birth weight 6.68 lb 6.76 lb 7.18 lb

Birth length 19.3 in 19.2 in 19.9 in

Preterm birth 18.2% 13.9% 13.7%

NICU admission 9.1% 4.8% 7.7%

Fetal/neonatal death 6.3% 4.6% 0%


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NS-Continued SHS

NS-Reduced/ Eliminated SHS

Continued Smoking

Quit Smoking

Birth weight 6.84 lb 7.03 lb 6.68 lb 7.18 lb

Birth length 19.3 in 19.6 in 19.3 in 19.9 in

Preterm birth 22.0% 11.7% 18.2% 13.7%

NICU admission 21.4% 8.7% 9.1% 7.7%

Fetal/neonatal death 5.7% 4.7% 6.3% 0%

Conclusions and ImplicationsConclusions and Implications

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• TIPS program, especially case management services, have been well received (8% refusal rate)

• Complete pregnancy smoking cessation rate of 8% is comparable to rates of other similar programs

• Program was highly effective at getting participants to reduce their level of smoking (over half)

• Program was effective at getting womento make at least one quit attempt (20%)


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• Program was very effective at getting women to reduce or eliminate SHS exposure (only one quarter continued at same rate)

• Program was highly effective at reducing smoking recidivism among recent quitters (90% remained smoke-free)


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Factors associated with successful smoking cessation:

• 4+ case manager meetings

• Use of the TIPS book

• Outside referrals, including for partner


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Factors associated with successful smoking reduction:

• In-depth counseling

• Information on stress reduction, relapse prevention, and cessation for others

• Assistance with practical issues

• Outside referrals, including for counseling


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Factors associated with quit attempts:• Multiple case manager

meetings• Two or more 5 A’s

sessions• Information on mental

health issues and cessation for others

• Outside referrals, including for counseling


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Factors unrelated to change in smoking behavior:

• Seeing a case manager in the first trimester

• Seeing a case manager only once

An approach that involves repeated contact and multiple types of assistance is

clearly best.


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• Women who quit smoking during pregnancy see substantially improved birth outcomes over those who continue to smoke

• Even women who reduce, but don’t quit smoking completely, see improved birth outcomes, especially in terms of decreased risk for PTB and associated outcomes


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• Initial data suggest that SHS exposure has a much larger impact on birth outcomes than previously reported

• Compared to babies of those who smoked early in pregnancy but quit, babies born to non-smokers with continued significant SHS exposure were:

• 6 ounces lighter• more than half an inch shorter• almost twice as likely to be born preterm• three times more likely to be admitted to the NICU


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Recent program modifications:

• Focus on multiple contacts• Provision of multiple and varied services• Greater focus on reducing/eliminating second

hand smoke exposure• While cessation is ultimate goal, enhanced

focus on smoking reduction among those unwilling to quit

Final WordFinal Word

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• Efforts to reduce pregnancy smoking/smoke exposure can be effective and lead to substantial improvements in birth outcomes

• To be successful, programs should also address

environmental and lifestyle factors that contribute to smoking/smoke exposure continuation

Select ResourcesSelect Resources

• 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)

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Pregnancy Smoking Intervention in Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data NE Tennessee: Effectiveness Data from the First Two Years of TIPSfrom the First Two Years of TIPS

Beth A. Bailey, PhDAssociate Professor of Family Medicine

Director, Tennessee Intervention for Pregnant Smokers

East Tennessee State University

Documents

Pregnancy Smoking Intervention in NE Tennessee: Effectiveness Data from the First Two Years of TIPS Beth A. Bailey, PhD Associate Professor of Family Medicine