Using 5 A’s and Incentives to Promote Prenatal Smoking Cessation

PI: Rebecca J. Donatelle, PhD, CHESPC: Deanne Hudson, RN, MPH, CHES

Co-PI: Edward Lichtenstein, PhDCo-Investigators:

Michael Wall, MD; Oregon Health Sciences UniversityNancy Davis, MPH; Providence Health System COREAdvisor: Chuck Benz, MD; Providence Health System

Funded by RWJF- Smoke-Free Families: Phase II

Outline of Presentation

Overview

Previous Research:

Oregon WIC Outcomes and Conclusions

Overview MISS Project

MISS Progress to Date

Negative Outcomes From Prenatal Smoking

Low birthweight (20%)

Preterm Birth (8%)

Perinatal Death (5%)

SIDS

Respiratory Illnesses

Decreased lung function

* CT Orleans et al (2000)

Previous Projects: SOS I, II & III(Donatelle*, Prows*, Hudson, Champeau)

3-4 Pronged Approaches Positive incentives (vouchers) to participants alone

or participants and partners for biochemically confirmed quits

Social support/partners (bolstered and natural)

Community participation

Biomarker feedback

Contingency Management (Rewards) Theory

Drug abuse is a form of operant behavior that is maintained in part by the reinforcing effects of the drug (Higgins 1996, 1997)

Non-drug reinforcer should decrease drug use (Roll et al 1996, Higgins 1997)

Voucher incentives provided when drug-free (Silverman et al 1996, Higgins 1997)

Measures/Biochemical Confirmation(MISS)

Utilize variety of measures/collection methods Follow Evidence Based Recommendations

Values for quit: Saliva Cotinine (GCMS) 30 ng/ml CO Expired air 05 ppm

Summary of SOS-I (RWJF–SFF: I)

Study

Tailored

Education /Advice

Choose Partner

Woman

Incentives / Month

Quit

%

SOS – I

RCTCx 108

Tx 112

YES

YES

-

$50./$25.

-

$50.

9

32Donatelle*, Prows*, Champeau, Hudson (2000)

Summary of SOS-II (RWJF)

Study

Tailored Education

/ AdviceChoose Partner

Woman Incentives

/ MonthQuit

%

SOS-II

Pilot

N = 62 YES YES $50. 28

Donatelle, Prows, Hudson

Summary of SOS – III (OHD)

Study

Tailored Education

/ AdviceChoose Partner

Woman Incentives

/ MonthFeed-back

Quit %

SOS – III

RCT

Cx 60

Tx1 67

Tx2 59

YES

YES

YES

-

YES

YES

-

$25.

$25.

-

-

YES

12

19

22

Donatelle, Prows, Hudson

SOS I, II & III: Quit Rates at 8 months Gestation (%)

9

32

28

12

1922

0

5

10

15

20

25

30

35

SOS I Cx

SOS I Tx

SOS II

SOS III Cx

SOS III Tx1

SOS III Tx2

I-C I-Tx II III Cx III Tx1 III Tx2

Conclusions from SOS I, II & III Best Practice-4 A’s are promising in WIC

? Would this be effective in private practice/Medicaid Incentives (Contingency Management) seem to be

effective ? What is the threshold for peak behavioral outcome

Biomarker feedback Partner Support …? Utilized various biochemical measures of quit

- may be an important component of the intervention itself

Maternal Interventions to Stop Smoking (MISS) Project

Purpose: To significantly increase smoking cessation behavior among predominantly low-income, high risk, pregnant women

9 Oregon private practice prenatal clinics Quit Confirmation (CO and Salivary Cotinine) RCT: 3 group design

Best Practice 5 A’s Best Practice 5 A’s plus $25/month voucher Best Practice 5 A’s plus $75/month voucher

Eligibility Criteria

Pregnant smoker (smoked even a puff in the last seven days)

15 years of age or older

< 29 weeks gestation at first OB visit

English speaker/reader

MISS Objectives

Determine whether incentives are more effective than Best Practice in motivating pregnant smokers to quit

To assess whether a higher incentive will result in a greater level of smoking cessation than a lower level incentive

Secondary Project ObjectivesDetermine:

The integrity/consistency of the intervention as delivered in private practice managed care clinics utilizing process measures from both women and providers.

The importance of selected psychosocial/environmental factors as predictors of smoking cessation/reduction in this population.

The cost-per-quit implications for an incentives model provided in a private practice managed care clinic.

MISS Methods

Screen all pregnant patients at 1st prenatal visit

Determine eligibility

Obtain informed consent – Randomized by patient

Provider 5A’s

A Pregnant Woman’s Guide to Quit Smoking

Importance of quitting during pregnancy

Local cessation resource guide

MISS Methods Continued

Incentives to Treatment Group Quitters

Follow monthly through 8 months gestation

Postpartum telephone assessments of quitters with salivary collection from nonsmokers

Best Practice 5 A’s

Ask Advise Assess Assist

A Pregnant Woman’s Guide to Quit Smoking Local area cessation resource list

Arrange

Summary of MISS Project (RWJF-SFF:II)

Tailored

Education

/Advice

Local Resource Pamphlet

Woman Incentives

/ Month

MISS-RCT

Cx

Tx 1

Tx 2

YES

YES

YES

YES

YES

YES

-

$25.

$75.

MISS Project To Date

Activity Pilot

RCT

(8/01-9/02)

Screened 787 2,751

Eligible 136 430

Enrolled 84 298Goal: 600

Participation Rate 62% 69%

MISS Project Baseline Summary (n=298)

Medicaid/Oregon Health Plan (%) 79

Private Insurance (%) 24

Mean Maternal Age (yrs.) 24.1

Mean Education (yrs.) 11.9

MISS RCT: Light Smokers (<10) and Heavy Smokers at Baseline by R Group (n=293)

62

40

59

37

60

35

0

10

20

30

40

50

60

70

# Women

Control $25 $75

R Group

Light

Heavy

Lessons Learned as of Today!

Intervention dependent on fast turn-around for reinforcement, difficult to find a lab able to comply at any cost

Although Providers are interested in smoking cessation during pregnancy and say it is a priority – they report TIME pressures and demands

Continued clinic monitoring & support/staff trainings/booster sessions a MUST…

MORE Lessons Learned

Incentives to Clinics

Locate Internal Champion in Clinics

Research Overlay is Staff Intensive

Local Resource List: Providers have Little Idea of What is Going on in Community Available for ALL Patients

More…..

Important to be connected in State/Region

Many agencies/programs/other funded projects promote 5A’s

Cooperation/collaboration important

References

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. June 2000.

Orleans CT, Barker DC, Kaufman NJ, et al. Helping Pregnant Smokers Quit: Meeting the Challenge in the Next Decade. Tobacco Control 2000;9(Suppl III):iii6-iii11.

Donatelle RJ*, Prows S*, Champeau D, et al. Randomized Controlled Trial Using Social Support and Financial Incentives for High Risk Pregnant Smokers: The Significant-Other Supporter (SOS) Program. Tobacco Control 2000;9(Suppl III):iii67-69.

References - more Higgins ST. Some Potential Contributions of Reinforcement and

Consumer-Demand Theory to Reducing Cocaine Use. Addict Behav 1996;21(6):803-816.

Higgins ST. The Influence of Alternative Reinforcers on Cocaine Use and Abuse: A Brief Review. Pharmacology Biochemistry and Behavior 1997;57(3)419-427.

Silverman K, Wong CJ, et al. Increasing Opiate Abstinence Through Voucher-Based Reinforcement Therapy. Drug and Alcohol Dependence 1996;41:157-165.

Roll JM, Higgins ST, et al. An Experimental Comparison of Three Different Schedules of Reinforcement of Drug Abstinence Using Cigarette Smoking as an Exemplar. Journal of Applied Behavior Analysis 1996;29:495-505.