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Smoke Free Families: A Tobacco Control Program for Pregnant Women and Their Families
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PRINCIPLES & PRACTICE
Smoke Free Families: A Tobacco Control Program for Pregnant Women and Their Families Pamela K. Pletsch, RN, PhD, Sarah Morgan, RN, MS, CNM
Tobacco use during pregnancy continues to cause health problems for women and children. Nurses can facilitate smoking cessation during pregnancy through the use of tobacco control guidelines and counseling tailored to pregnant women. In this article, the Treating Tobacco Use and Dependence: Clinical Practice Guideline is reviewed; the Smoke Free Families program, which is tailored for pregnancy, stage matched, and includes second-hand smoke control assistance, is described; and two models for integrating smoking cessation counseling into prenatal services are offered. JOGNN, 31, 39–47; 2002. Keywords: Clinical practice guidelines—Community-based intervention—Pregnancy—Smoking cessation Accepted: June 2001 Tobacco use among pregnant women and children’s exposure to tobacco smoke are associated with substantial morbidity for women and children. Maternal smoking is associated with premature birth and intrauterine growth restriction (Ahluwalia, Grummer-Strawn, & Scanlon, 1997; Cnattingius & Haglund, 1997; Heinonen, Ryynanen, & Kirkinen, 1999; Nordentoft et al., 1996). Neonates and young children who are exposed to secondhand smoke in their homes are at increased risk for developing asthma and other respiratory disorders later in childhood and for dying from sudden infant death syndrome (Barber, Mussin, & Taylor, 1996; Cook & Strachan, 1999; Li, Peat, Xuan, & Berry, 1999; Mannino, Siegel, Husten, Rose, & Etzel, 1996).
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The Healthy People 2000 (U.S. Department of Health and Human Services [DHHS], 1991) smoking reduction goals for pregnant women were not met, and the 2010 targets are ambitious. In the United States, the percentages of women who smoke cigarettes during pregnancy vary according to race, ethnicity, age, educational levels, and geographic region. In 1996, the percentages of women who smoked during pregnancy ranged from less than 1% to 31%, with an average of 14% (Centers for Disease Control and Prevention, 2001; National Center for Health Statistics, 1998). In 1991, 12% of pregnant women who smoked cigarettes quit during the 1st trimester (DHHS, 2000b). Thus, the Healthy People 2010 target of 30% smoking cessation by pregnant women creates a challenge to all who care for pregnant women (DHHS, 2000a). Secondhand smoke exposure for children also remains a problem. In 1994, 24% of children age 6 or younger were exposed to secondhand smoke in their homes, which is far from the 2010 target of 10% (DHHS, 2000b). Much is known about the basics of tobacco control counseling, but more work is needed if we are to improve maternal and infant health (DHHS, 2000a; Mullen, 1999; Windsor & Boyd, 1998; Windsor et al., 2000). Tailoring programs for pregnant women and their families will help us attain the 2010 goals (Lichtenstein, 1997). Because of nurses’ expertise in health promotion and disease prevention, in-depth understanding of women and their families, and the practice of providing holistic care, those who provide antepartum or postpartum care are well positioned
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to provide tobacco control counseling. The regular contact that nurses have with women during the prenatal and postpartum periods creates an opportunity to provide the continuity of care necessary for tobacco control counseling, monitoring of exposure, and support for women’s successes. The Smoke Free Families (SFF) program captures the teachable moment of pregnancy to help women quit smoking and remove secondhand smoke from their homes. SFF is a moderately intensive program designed to be part of a woman’s prenatal care and an adjunct to brief tobacco control counseling. In this article, we review the Treating Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al., 2000), describe the SFF program, and propose two models for integrating SFF into prenatal care services.
& Stoddard, 2000; Wright et al., 1997). Providers are advised to weigh the risks of continued tobacco use with the risk of drug therapy and the likelihood that a client will be successful in abstaining from tobacco. The first-line therapies come with different levels of cautions. Nicotine replacement therapy in the form of the patch (transdermal) or gum (nicotine polacrilex) is avail-
Tobacco Control Guideline
able over the counter. The nicotine inhalation system and nasal spray are available by prescription (Nordenberg, 1999; NP Prescribing Reference, 2000; Physician’s Desk Reference, 2000). Nicotine gum is classified as a pregnancy category C drug, whereas all other nicotine replacement therapies are category D (Oncken et al., 2000). Buproprion hydrochloride is a category B drug (Nordenberg, 1999; Physician’s Desk Reference, 2000). Because pharmacologic agents carry risks for use during pregnancy, programs such as SFF, which provide counseling, support, and behavioral strategies for smoking cessation, are especially important.
Brief Office-Based Counseling The U.S. Public Health Service has supported the development of clinical practice guidelines for tobacco control (Fiore et al., 1996, 2000). The most recent version, Treating Tobacco Use and Dependence: Clinical Practice Guideline, was the result of a partnership between the U.S. government and nonprofit organizations and is available via the Internet at www.surgeongeneral.gov/ tobacco (Fiore et al., 2000). In the guideline, steps for office-based tobacco control counseling are outlined. The guideline includes modifications for the use of pharmacotherapies during pregnancy. The guideline consists of five “A’s”: ask, advise, assess, assist, and arrange (Fiore et al., 2000). The first step is to assess and document tobacco use (ask). Clients identified as tobacco users are urged to quit (advise). The third step is to assess clients who use tobacco for their willingness to attempt cessation (assess). If a client is not interested in cessation, the health care provider’s goal is to increase the client’s motivation. For clients who are interested in cessation, providers offer brief counseling, referrals, and/or pharmacotherapies (assist). The last step of the guideline calls for follow-up contacts by the provider to monitor progress (arrange) (see Figure 1). The SFF is an example of the kind of program to which women can be referred during the “assist” step. The SFF program includes client-specific counseling, skill development, support, and secondhand smoke control planning.
Pharmacotherapy There is research-based evidence that pharmacotherapies enhance smoking cessation outcomes (Fiore et al., 2000). The use of pharmacotherapies by pregnant women, however, is controversial (Ogborn et al., 1999; Oncken et al., 1996, 1997; Oncken, Pbert, Ockene, Zapka, 40 JOGNN
T
he Healthy People 2010 target of smoking cessation by 30% of pregnant smokers is a challenge to perinatal nurses.
Smoke Free Families Program Description SFF is a moderately intensive home visit program tailored for pregnant women. A registered nurse makes two home visits, with a 2-week interval between visits, and follow-up telephone calls. Home visits enable the nurse to assess the home environment and engage family members in the tobacco control process. The counseling provided is stage matched, pregnancy specific, firm, direct, and includes information about health risks to the woman and fetus (see Figure 2).
Pregnancy-Specific Counseling SFF counseling includes assisting the pregnant woman to increase her awareness of her smoking patterns. For example, the woman is encouraged to think about when she is most likely to smoke. What benefits does smoking bring to her? What are the specific triggers or situations in which she is most likely to want or need a cigarette? Health risks to the woman are discussed, including maternal respiratory problems, risks associated with anesthesia during childbirth, and eventual risks for cancer and cardiovascular diseases. The nurse describes fetal health Volume 31, Number 1
Ask (Screen for and document tobacco use)
No
Yes
Advise to quit
Motivate
Assess readiness to quit
No Yes Assist Brief counseling
Refer
Arrange
Pharmacotherapy
Smoke Free Families
(Follow-up & Monitor Progress)
FIGURE 1
Flowchart for tobacco control counseling during pregnancy. Note. Adapted from Fiore et al. (2000).
risks, such as spontaneous abortion and preterm and small-for-gestational-age newborns. Neonatal health problems, such as respiratory difficulties and sudden infant death syndrome, are discussed. Because pregnant women may feel guilty about smoking, counseling is nonjudgmental and supportive. Each success, regardless of how small, is celebrated (Pletsch, 1995).
Stage-Matched Counseling The stage-matched counseling in the SFF program is tailored to the pregnant woman’s readiness to quit smoking (Cancer Prevention Research Consortium, 1995). In January/February 2002
this cognitive behavioral approach to smoking cessation, behavior change is viewed as a process in which people move back and forth among the stages of precontemplation, contemplation, preparation, action, and maintenance (DiClemente et al., 1991; Prochaska & Velicer, 1997). During the precontemplation stage, the goal is to stimulate the smoker to think about the role smoking plays in her life, for the smoker to contemplate the benefits of quitting, and for the nurse to provide the smoker with information about the disadvantages of smoking (see Figure 2). During the contemplation stage, the goal is for a
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Part 1
Basics ¾ ¾ ¾
Assess stage of change Enhance client’s self awareness of smoking patterns Discuss health risks for woman and fetus
¾
Part 2 Stage-Matched Counseling
Precontemplation Increase thoughts of smoking patterns Discuss benefits of quitting Provide client with additional information ¾
Contemplation Identify personal benefits & barriers Make small changes in smoking ¾
¾
¾
Preparation Increase confidence that now is the time to quit Choose a cessation method & date Make small changes in smoking
Action Increase confidence that success is possible Identify tempting situations and alternatives Set a quit date Select people for social support Inform client of potential nicotine withdrawal
Maintenance Identify rewards for quitting Discuss healthy eating & exercise “Slip” management Potential postpartum resumption of smoking
Part 3
Additional Components Support Materials Living Smoke Free: A Healthier Start for You and Your Baby (booklet) The Feminine Mistake (video) Smoking and Pregnancy (ALA flip chart) Doppler for fetal heart tones
¾ ¾ ¾
Deep breathing and progressive relaxation Listening to fetal heart tones Second-hand smoke control plan
FIGURE 2
Smoke Free Families Program essentials.
smoker to identify the benefits and barriers to quitting and to get ready to quit by making small behavioral changes, such as reducing the number of cigarettes she smokes each day. During the preparation stage, the goal is for a smoker to increase her confidence that this is a 42 JOGNN
good time to quit, with the nurse assisting the smoker in developing a cessation plan. Strategies for the woman include beginning to think of herself as a nonsmoker, choosing a cessation method, setting a quit date, and making small changes in her smoking. During the action Volume 31, Number 1
stage, the goal is for the smoker to increase her confidence that she can be successful. The nurse helps the smoker acquire the requisite skills. Each smoker identifies situations in which she is tempted to smoke, creates alternatives to smoking, sets a quit date, identifies people for social support, and prepares for nicotine withdrawal symptoms. The goal for the woman who has quit but who does not yet identify herself as a nonsmoker is to maintain her quit status. Counseling strategies include encouraging the woman to reward herself for quitting and to continue a healthy lifestyle. The possibilities of occasional slips or postpartum resumption of smoking and strategies for continuing the quit attempt are discussed.
The First Home Visit The SFF program begins by identifying a woman as a tobacco user. The nurse, midwife, or physician advises her to quit and schedules the first home visit. During the first visit, the nurse assesses the woman’s stage of change and provides her with pregnancy-specific and stage-matched tobacco counseling as described above. For example, if
T
he SFF program is a useful adjunct to the Treating Tobacco Use and Dependence: Clinical Practice Guideline.
the woman is in the precontemplation stage, SFF counseling focuses on self-awareness of smoking patterns, information about health risks, advantages of cessation, and resources where the woman can find more information. The outcome desired is for the woman to begin thinking about quitting and continue through the other stages until she becomes a nonsmoker. Counseling is reinforced through the booklet, Living Smoke Free: A Healthier Start for You and Your Baby, which includes stagematched strategies (Boyd, Ershoff, & Quinn, 1996). Each woman is given this booklet, which includes a description of the health risks of smoking for women and fetuses. Women view segments of the videotape, the Feminine Mistake (David Bell Associates, 1989). In the first segment, the nicotine-induced peripheral vasoconstriction that occurs after a woman smokes a cigarette is demonstrated. In discussing the video, the nurse draws parallels between the demonstration and the effect that nicotine has on placental perfusion. In the second segment, an interaction between a physician and a pregnant woman during an ultrasound fetal evaluation is shown, and the effects of cigarette smoking on the fetus and newborn are discussed. The nurse expands on the information provided in the video, answers questions, and uses a flip chart to January/February 2002
illustrate physiologic effects of nicotine and carbon monoxide on the fetus (American Lung Association, 1982). Control of secondhand smoke in the home is part of the SFF program. The pregnant woman and nurse assess smoking in the home, problem-solve issues, and form a plan to eliminate or reduce smoking in the home. The health risks of secondhand smoke for children who live in the home and for the newborn are discussed. If family members are present, they are invited to join in the development of the plan. The nurse’s observation of the home helps in developing the secondhand smoke control plan. At the end of the visit, the pregnant woman identifies at least one counseling-related activity that she agrees to do before to the next home visit. Deep breathing and progressive relaxation exercises are practiced so that the visit ends with the woman feeling good (Pletsch, 1999). In addition, the woman is encouraged to use the exercises to manage stress during pregnancy and for relaxation during childbirth. The first visit typically lasts 45 minutes to an hour.
The Second Home Visit The second visit occurs 2 weeks later. The nurse and the pregnant woman evaluate the usefulness of the strategies the woman has used since the first visit. The nurse provides support and praise for the woman’s efforts. If the woman has moved to the next stage of change, new staged-matched counseling is provided. If the woman is at the same stage, activities are reviewed, reassessed, and revised. The woman and family members listen to fetal heart tones via Doppler, which enhances the woman’s awareness of the fetus, is enjoyable, and provides an opportunity for additional discussion of the effects of smoking on the fetus. The secondhand smoke control plan is reviewed and revised. The visit ends with deep breathing and progressive relaxation exercises. The second home visit lasts approximately 30 minutes.
Follow-Up For the duration of a woman’s pregnancy, the nurse conducts brief follow-up counseling with monthly telephone calls. Progress and pitfalls are assessed, and new plans are discussed. For women who quit smoking, the nurse discusses “slips,” occasions in which a person smokes a cigarette or two but remains in the action stage of quitting. Methods for avoiding postpartum resumption of smoking are discussed. These methods include anticipating tempting situations and avoiding them, being aware of the warning signs of smoking resumption, and shifting one’s focus to the benefits of not smoking. Women are encouraged to use the stress management skills developed while quitting, such as resting while the infant sleeps and asking for support from others.
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Models Integrating SFF Into Prenatal Care The ideal delivery format for the SFF program, based on focus group discussions with pregnant women, was as described above. Many obstetric practices, however, do not have the personnel or financial resources for home visiting (Dicky, Gemson, & Carney, 1999; Lia-Hoagberg, Schaffer, & Strochschein, 1999). The delivery method for the SFF program can be modified to fit the structure, resources, and philosophy of a practice by varying the health care providers who do the counseling, the clustering of program components, and the setting. Two such delivery modifications are described below.
Adaptations for Office-Based Counseling In this variation, a team approach is used to implement the guideline steps and the SFF program. For example, medical assistants or nursing staff screen women and document their tobacco use. Nurses, nurse-midwives, or physicians advise the woman to quit smoking. The SFF program is then implemented in 5- to 10-minute segments during regular prenatal visits. For example, the following activities can be implemented during separate visits by office staff: assess stage of change, provide stage-matched counseling, provide the woman with the booklet, assess secondhand smoke in the home, teach and practice deep breathing and progressive relaxation, show the video, discuss smoking-related health risks, and monitor progress. If available, a community outreach worker can assist the pregnant woman in developing the secondhand smoke control plan. Registered nurses can make the follow-up telephone calls or schedule time to meet with the woman during each prenatal visit. Documentation of assessments, counseling, and outcomes is available to team members in the woman’s medical record. The team approach requires good communication and documentation systems but results in tobacco control counseling being well integrated into prenatal care services. A disadvantage of counseling that is purely office based is that nurses are not able to directly assess and intervene regarding smoking activities in the home. For example, if a young pregnant woman lives with her parents who smoke, the home visit nurse can function as an advocate for the young woman in negotiating with parents to remove or reduce smoking in their home.
Coordination With Existing Nurse Home-Visiting Programs In the second variation, the office staff collaborates with the home-visiting staff of community organizations. Many communities have pregnancy-related home-visiting programs funded by local, state, or federal maternalchild/infant programs; health insurance companies; or nonprofit organizations. The SFF program can be delivered through the collaboration of office or clinic staff and 44 JOGNN
home-visiting nurses. In this delivery model, brief counseling, as recommended by the tobacco control guideline, is provided by office-based providers. When a woman is identified as a tobacco user, a referral, with her permission, is sent to a nurse in the home-visiting program.
T
he SFF program can be modified to fit the structure, resources, and philosophy of an obstetric practice by varying the personnel who provide the counseling, the clustering of program components, and the setting.
The SSF activities can be broken down into four to six sessions of 10 to 15 minutes each. The home-visiting nurse implements these shorter sessions as part of her regular visit. An example of a four-visit program follows. During the first home visit, the nurse assesses the woman’s stage of change and the secondhand smoke situation in the home. Deep breathing and progressive relaxation exercises are practiced. During the second visit, the video is viewed, smoking-related health risks are discussed, and the booklet is presented. During the third visit, stage-specific counseling takes place. During the fourth visit, the secondhand smoke plan is developed, fetal heart tones are heard, and the usefulness of activities is evaluated. At each subsequent home visit, the nurse provides support, reinforcement, and counseling. Communication between the home-visiting nurse and the office nurse about a woman’s progress is important. Ideally, electronic records make the visiting nurse’s notes available to the office staff, so they can reinforce the visiting nurse’s counseling and monitor the woman’s progress. In the absence of such electronic capability, notes can be sent via fax or mail. Thus, the office staff can implement the “arrange” guideline step through referral and monitoring of a woman’s tobacco use status. The SFF program is theoretically based and adaptable to a variety of delivery models. Tobacco control programs for pregnant women have been structured in various ways (Windsor & Boyd, 1998), including brief intervention as part of routine prenatal care (Ebrahim, Floyd, Merritt, Decoufle, & Holtzman, 2000; Windsor et al., 1993, 2000), group programs for pregnant women (Pletsch, 1995; Pohl & Caplan, 1998), multiple component programs (Ershoff, Mullen, & Quinn, 1989; Gebauer, Kwo, Haynes, & Wewers, 1998; Klerman & Rooks, 1999; Klesges, Ward, & DeBon, 1996; Pletsch, Devine, Payne, Volume 31, Number 1
& London, in press; Secker-Walker, Solomon, Flynn, Skelly, & Mead, 1998; Walsh, Redman, Brinsmead, Byrne, & Melmeth, 1997), and individual counseling (Orleans & Slade, 1993). The SFF program was designed to be consistent with the tobacco control guideline, be a more intensive adjunct to brief office-based counseling, and include assessment of the home environment. Nurses can develop a system in which the SFF program is used in conjunction with the Treating Tobacco Use and Dependence: Clinical Practice Guideline, selecting a delivery model that fits their clients, practice, and community.
Evaluation Strategies SFF Research The SFF program is being evaluated in two funded, longitudinal, randomized controlled trials with differing populations of pregnant women and their families. Women are randomized to treatment or usual care control conditions, and data are collected at preintervention, postintervention, and 36 weeks gestation. Variables include stage of change, processes of change, self-efficacy, family support, smoking status, and secondhand smoke exposure. The biologic marker of salivary cotinine is used to verify cessation. Although this evaluation is not yet complete, the components of the SFF program are well enough established for nurses to use it with their patients.
SFF Clinical Outcomes Evaluation Clinicians can evaluate the effectiveness of the SFF program with their patient populations by monitoring smoking-related outcomes. One category of outcomes is tobacco smoke exposure and includes documentation of the percentage of pregnant patients who reduce smoking, quit smoking, or create smoke-free households. This information can be recorded on the vital signs sheet at each prenatal visit (Fiore et al., 2000; Pletsch et al., in press). Perinatal complications is a second category of outcomes, but a large number of patients is required to be meaningful. Examples of such outcomes are rates of preterm labor and of births of small for gestation newborns (Nordentoft et al., 1996). The clinical evaluation process requires the establishing of monitoring and documentation systems, identifying of baseline rates for the outcomes selected, training of staff, implementing of the SFF program, and monitoring of changes in outcomes. Nurses can increase their contributions to the health of their pregnant clients and their clients’ families by integrating tobacco control counseling into prenatal care. With similar efforts by all who provide health care to pregnant women, we will move closer to the Healthy People 2010 goals.
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Acknowledgments This work was supported by grants from the National Institutes of Health (R15 NINR 04213) and the American Lung Association of Wisconsin. REFERENCES Ahluwalia, I. B., Grummer-Strawn, L., & Scanlon, K. S. (1997). Exposure to environmental tobacco smoke and birth outcome: Increased effects on pregnant women aged 30 years or older. American Journal of Epidemiology, 146(1), 42-47. American Lung Association. (1982). Smoking and pregnancy: Flip chart for health care providers (Publication No. 1/88 0432B). Milwaukee, WI: Author. Barber, K., Mussin, E., & Taylor, D. K. (1996). Fetal exposure to involuntary maternal smoking and childhood respiratory disease. Annals of Allergy Asthma and Immunology, 76, 427-430. Boyd, N. R., Ershoff, D., & Quinn, V. (1996). Living smoke free: A healthier start for you and your baby. San Bruno, CA: Krames Communications. Cancer Prevention Research Consortium. (1995). Pathways to health. Kingston: University of Rhode Island. Centers for Disease Control and Prevention. (2001). Women and smoking: A report of the surgeon general. Tobacco use and reproduction outcomes—fact sheet. Washington, DC: Author. Cnattingius, S., & Haglund, B. (1997). Decreasing smoking prevalence during pregnancy in Sweden: The effect on small-for-gestational-age births. American Journal of Public Health, 87, 410-413. Cook, D. G., & Strachan, D. P. (1999). Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax, 54, 357-366. David Bell Associates. (1989). The feminine mistake: The next generation. Santa Monica, CA: Pyramid Film & Video. DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295-304. Dicky, L. L., Gemson, D. H., & Carney, P. (1999). Office system interventions supporting primary care-based health behavior change counseling. American Journal of Preventative Medicine, 17(4), 299-308. Ebrahim, S. H., Floyd, R. L., Merritt, R. K., Decoufle, P., & Holtzman, D. (2000). Trends in pregnancy-related smoking rates in the United States, 1987-1996. Journal of the American Medical Association, 283(3), 361-366. Ershoff, D. H., Mullen, P. D., & Quinn, V. P. (1989). A randomized trial of serialized self-help smoking cessation program for pregnant women in an HMO. American Journal of Public Health, 79, 182-187. Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Grtiz, E. R., et al. (1996). Smoking cessation: Clinical practice guideline (AHCPR Publication No. 96-
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0692). Rockville, MD: Agency for Health Care Policy and Research. Fiore, M. C., Bailey, W. C., Cohen, S. J, Dorfman, S. F., Goldstein, M. G., Grtiz, E. R., et al. (2000). Treating tobacco use and dependence: Clinical practice guideline. Washington, DC: U.S. Department of Health and Human Services, Public Health Service. Gebauer, C., Kwo, C. Y., Haynes, E. F., & Wewers, M. E. (1998). A nurse-managed smoking cessation intervention during pregnancy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 21, 47-53. Heinonen, S., Ryynanen, M., & Kirkinen, P. (1999). The effects on fetal development of high alpha-fetoprotein and maternal smoking. American Journal of Public Health, 89, 561-563. Klerman, L. V., & Rooks, J. P. (1999). A simple, effective method that midwives can use to help pregnant women stop smoking. Journal of Nurse Midwifery, 44, 118-123. Klesges, R. C., Ward, K. D., & DeBon, M. (1996). Smoking cessation: A successful behavioral/pharmacologic interface. Clinical Psychology, 16(6), 479-496. Li, J.S.M., Peat, J. K., Xuan, W., & Berry, G. (1999). Metaanalysis on the association between environmental tobacco smoke (ETS) exposure and the prevalence of lower respiratory tract infection in early childhood. Pediatric Pulmonology, 27, 5-13. Lia-Hoagberg, B., Schaffer, M., & Strochschein, S. (1999). Public health nursing practice guidelines: An evaluation of dissemination and use. Public Health Nursing, 16(6), 397-404. Lichtenstein, E. (1997). Behavioral research contributions and needs in cancer prevention and control: Tobacco use prevention and cessation. Preventive Medicine, 5 Pt 2, S57-S63. Mannino, D. M., Siegel, M., Husten, C., Rose, H., & Etzel, R. (1996). Environmental tobacco smoke exposure and health effects in children: Results from the 1991 National Health Interview Survey. Tobacco Control, 5, 13-18. Mullen, P. D. (1999). Smoking during pregnancy and intervention to promote cessation: A meta-analysis. Primary Care: Clinics in Office Practice, 26, 577-589. National Center for Health Statistics. (1998). Health, United States, 1998. With socioeconomic status and health chartbook. Hyattsville, MD: Author. Nordenberg, T. (1999). It’s quittin’ time—Smokers need not rely on willpower alone. FDA Consumer (Publication No. FDA 99-1288), 1-7. Nordentoft, M., Lou, H. C., Hansen, D., Nim, J., Pryds, O., Rubin, P., & Hemmingsen, R. (1996). Intrauterine growth retardation and premature delivery: The influence of maternal smoking and pyschosocial factors. American Journal of Public Health, 86, 347-354. NP Prescribing Reference. (2000). Vol. 7, No. 2. New York: Prescribing Reference Inc. Ogborn, P. L., Hurt, R. D., Croghan, I. T., Schroeder, D. R., Ramin, K. D., & Moyer, T. P. (1999). Nicotine patch use in pregnant smokers: Nicotine and cotinine levels and fetal effects. American Journal of Obstetrics and Gynecology, 181, 736-743. Oncken, C. A., Hardardottir, H., Hatsukami, D., Lupo, V., Rodis, J., & Smeltzer, J. (1997). Effects of transdermal
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nicotine or smoking on nicotine concentrations and maternal-fetal hemodynamics. Obstetrics & Gynecology, 90, 569-574. Oncken, C. A., Hatsukami, R. J., Lupo, V. R., Lando, H. A., Gibeau, L. M., & Hansen, R. J. (1996). Effects of shortterm nicotine gum use in pregnant smokers. Clinical Pharmacologic Therapy, 59, 654-661. Oncken, C. A., Pbert, L., Ockene, J. K., Zapka, J., & Stoddard, A. (2000). Nicotine replacement prescription practices of obstetric and pediatric clinicians. Obstetrics and Gynecology, 96(2), 261-265. Orleans, C. T., & Slade, J. (1993). Nicotine addiction: Principles and management. New York: Oxford University Press. Physician’s Desk Reference. (2000). Montvale, NJ: Medical Economics Company. Pletsch, P. K. (1995). Pregnant Hispanics: Smoke free madres, a smoking cessation intervention. Final report submitted to the American Lung Association of Wisconsin. Pletsch, P. K. (1999). Smoke Free Families: A smoking cessation program for pregnant African-American women. Final report submitted to the American Lung Association of Wisconsin. Pletsch, P. K., Devine, E. C., Payne, J., & London, R. (in press). Adoption of a smoking cessation guideline in primary care: A case study. Clinical Excellence for Nurse Practitioners. Pohl, J. M., & Caplan, D. (1998). Smoking cessation: Using group intervention methods to treat low-income women. Nurse Practitioner, 23(12), 13-39. Prochaska, J. O., & Velicer, W. F (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48. Secker-Walker, R. H., Solomon, L. J., Flynn, B. S., Skelly, J. M., & Mead, P. B. (1998). Reducing smoking during pregnancy and postpartum: Physician’s advice supported by individual counseling. Preventive Medicine, 27(3), 422430. U.S. Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: Government Printing Office. U.S. Department of Health and Human Services. (2000a). Healthy People 2010 (conference edition, in two volumes). Washington, DC: Government Printing Office. U.S. Department of Health and Human Services. (2000b). Surgeon General’s report on smoking rates (press release). Atlanta, GA: CDC Office on Smoking and Health. Walsh, R. A., Redman, S., Brinsmead, M. W., Byrne, J. M., & Melmeth, A. (1997). A smoking cessation program at a public antenatal clinic. American Journal of Public Health, 87, 1201-1204. Windsor, R. A., & Boyd, N. R. (1998). A meta-evaluation of smoking cessation intervention research among pregnant women: Improving the science and art. Health Education Research, 13, 419-438. Windsor, R. A., Lowe, J. B., Perkins, L. L., Smith-Yoder, D., Artz, L., Crawford, M., et al. (1993). Health education methods for pregnant smokers: Its behavioral impact and cost benefit. American Journal of Public Health, 83, 201206.
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Windsor, R. A., Woodby, L. L., Miller, M., Hardin, J. M., Crawford, M. A., & DiClemente, C. C. (2000). Effectiveness of AHCPR practice recommendations and patient education methods for pregnant smokers in Medicaid maternity care. American Journal of Obstetrics & Gynecology, 182, 68-75. Wright, L. N., Thorp, J. M., Kuller, J. A., Shrewsbury, R. P., Ananth, C., & Hartmann, K. (1997). Transdermal nicotine replacement in pregnancy: Maternal pharmacogenetics and fetal effect. American Journal of Obstetrics & Gynecology, 176, 1090-1094.
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Pamela K. Pletsch is a professor in the School of Nursing, University of Wisconsin–Milwaukee. Sarah Morgan is a doctoral student in the School of Nursing, University of Wisconsin–Milwaukee. Address for correspondence: Pamela K. Pletsch, RN, PhD, P.O. Box 413, Milwaukee, WI 53201. E-mail: [email protected].
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PRINCIPLES & PRACTICE
Smoke Free Families: A Tobacco Control Program for Pregnant Women and Their Families Pamela K. Pletsch, RN, PhD, Sarah Morgan, RN, MS, CNM
Tobacco use during pregnancy continues to cause health problems for women and children. Nurses can facilitate smoking cessation during pregnancy through the use of tobacco control guidelines and counseling tailored to pregnant women. In this article, the Treating Tobacco Use and Dependence: Clinical Practice Guideline is reviewed; the Smoke Free Families program, which is tailored for pregnancy, stage matched, and includes second-hand smoke control assistance, is described; and two models for integrating smoking cessation counseling into prenatal services are offered. JOGNN, 31, 39–47; 2002. Keywords: Clinical practice guidelines—Community-based intervention—Pregnancy—Smoking cessation Accepted: June 2001 Tobacco use among pregnant women and children’s exposure to tobacco smoke are associated with substantial morbidity for women and children. Maternal smoking is associated with premature birth and intrauterine growth restriction (Ahluwalia, Grummer-Strawn, & Scanlon, 1997; Cnattingius & Haglund, 1997; Heinonen, Ryynanen, & Kirkinen, 1999; Nordentoft et al., 1996). Neonates and young children who are exposed to secondhand smoke in their homes are at increased risk for developing asthma and other respiratory disorders later in childhood and for dying from sudden infant death syndrome (Barber, Mussin, & Taylor, 1996; Cook & Strachan, 1999; Li, Peat, Xuan, & Berry, 1999; Mannino, Siegel, Husten, Rose, & Etzel, 1996).
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The Healthy People 2000 (U.S. Department of Health and Human Services [DHHS], 1991) smoking reduction goals for pregnant women were not met, and the 2010 targets are ambitious. In the United States, the percentages of women who smoke cigarettes during pregnancy vary according to race, ethnicity, age, educational levels, and geographic region. In 1996, the percentages of women who smoked during pregnancy ranged from less than 1% to 31%, with an average of 14% (Centers for Disease Control and Prevention, 2001; National Center for Health Statistics, 1998). In 1991, 12% of pregnant women who smoked cigarettes quit during the 1st trimester (DHHS, 2000b). Thus, the Healthy People 2010 target of 30% smoking cessation by pregnant women creates a challenge to all who care for pregnant women (DHHS, 2000a). Secondhand smoke exposure for children also remains a problem. In 1994, 24% of children age 6 or younger were exposed to secondhand smoke in their homes, which is far from the 2010 target of 10% (DHHS, 2000b). Much is known about the basics of tobacco control counseling, but more work is needed if we are to improve maternal and infant health (DHHS, 2000a; Mullen, 1999; Windsor & Boyd, 1998; Windsor et al., 2000). Tailoring programs for pregnant women and their families will help us attain the 2010 goals (Lichtenstein, 1997). Because of nurses’ expertise in health promotion and disease prevention, in-depth understanding of women and their families, and the practice of providing holistic care, those who provide antepartum or postpartum care are well positioned
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to provide tobacco control counseling. The regular contact that nurses have with women during the prenatal and postpartum periods creates an opportunity to provide the continuity of care necessary for tobacco control counseling, monitoring of exposure, and support for women’s successes. The Smoke Free Families (SFF) program captures the teachable moment of pregnancy to help women quit smoking and remove secondhand smoke from their homes. SFF is a moderately intensive program designed to be part of a woman’s prenatal care and an adjunct to brief tobacco control counseling. In this article, we review the Treating Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al., 2000), describe the SFF program, and propose two models for integrating SFF into prenatal care services.
& Stoddard, 2000; Wright et al., 1997). Providers are advised to weigh the risks of continued tobacco use with the risk of drug therapy and the likelihood that a client will be successful in abstaining from tobacco. The first-line therapies come with different levels of cautions. Nicotine replacement therapy in the form of the patch (transdermal) or gum (nicotine polacrilex) is avail-
Tobacco Control Guideline
able over the counter. The nicotine inhalation system and nasal spray are available by prescription (Nordenberg, 1999; NP Prescribing Reference, 2000; Physician’s Desk Reference, 2000). Nicotine gum is classified as a pregnancy category C drug, whereas all other nicotine replacement therapies are category D (Oncken et al., 2000). Buproprion hydrochloride is a category B drug (Nordenberg, 1999; Physician’s Desk Reference, 2000). Because pharmacologic agents carry risks for use during pregnancy, programs such as SFF, which provide counseling, support, and behavioral strategies for smoking cessation, are especially important.
Brief Office-Based Counseling The U.S. Public Health Service has supported the development of clinical practice guidelines for tobacco control (Fiore et al., 1996, 2000). The most recent version, Treating Tobacco Use and Dependence: Clinical Practice Guideline, was the result of a partnership between the U.S. government and nonprofit organizations and is available via the Internet at www.surgeongeneral.gov/ tobacco (Fiore et al., 2000). In the guideline, steps for office-based tobacco control counseling are outlined. The guideline includes modifications for the use of pharmacotherapies during pregnancy. The guideline consists of five “A’s”: ask, advise, assess, assist, and arrange (Fiore et al., 2000). The first step is to assess and document tobacco use (ask). Clients identified as tobacco users are urged to quit (advise). The third step is to assess clients who use tobacco for their willingness to attempt cessation (assess). If a client is not interested in cessation, the health care provider’s goal is to increase the client’s motivation. For clients who are interested in cessation, providers offer brief counseling, referrals, and/or pharmacotherapies (assist). The last step of the guideline calls for follow-up contacts by the provider to monitor progress (arrange) (see Figure 1). The SFF is an example of the kind of program to which women can be referred during the “assist” step. The SFF program includes client-specific counseling, skill development, support, and secondhand smoke control planning.
Pharmacotherapy There is research-based evidence that pharmacotherapies enhance smoking cessation outcomes (Fiore et al., 2000). The use of pharmacotherapies by pregnant women, however, is controversial (Ogborn et al., 1999; Oncken et al., 1996, 1997; Oncken, Pbert, Ockene, Zapka, 40 JOGNN
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he Healthy People 2010 target of smoking cessation by 30% of pregnant smokers is a challenge to perinatal nurses.
Smoke Free Families Program Description SFF is a moderately intensive home visit program tailored for pregnant women. A registered nurse makes two home visits, with a 2-week interval between visits, and follow-up telephone calls. Home visits enable the nurse to assess the home environment and engage family members in the tobacco control process. The counseling provided is stage matched, pregnancy specific, firm, direct, and includes information about health risks to the woman and fetus (see Figure 2).
Pregnancy-Specific Counseling SFF counseling includes assisting the pregnant woman to increase her awareness of her smoking patterns. For example, the woman is encouraged to think about when she is most likely to smoke. What benefits does smoking bring to her? What are the specific triggers or situations in which she is most likely to want or need a cigarette? Health risks to the woman are discussed, including maternal respiratory problems, risks associated with anesthesia during childbirth, and eventual risks for cancer and cardiovascular diseases. The nurse describes fetal health Volume 31, Number 1
Ask (Screen for and document tobacco use)
No
Yes
Advise to quit
Motivate
Assess readiness to quit
No Yes Assist Brief counseling
Refer
Arrange
Pharmacotherapy
Smoke Free Families
(Follow-up & Monitor Progress)
FIGURE 1
Flowchart for tobacco control counseling during pregnancy. Note. Adapted from Fiore et al. (2000).
risks, such as spontaneous abortion and preterm and small-for-gestational-age newborns. Neonatal health problems, such as respiratory difficulties and sudden infant death syndrome, are discussed. Because pregnant women may feel guilty about smoking, counseling is nonjudgmental and supportive. Each success, regardless of how small, is celebrated (Pletsch, 1995).
Stage-Matched Counseling The stage-matched counseling in the SFF program is tailored to the pregnant woman’s readiness to quit smoking (Cancer Prevention Research Consortium, 1995). In January/February 2002
this cognitive behavioral approach to smoking cessation, behavior change is viewed as a process in which people move back and forth among the stages of precontemplation, contemplation, preparation, action, and maintenance (DiClemente et al., 1991; Prochaska & Velicer, 1997). During the precontemplation stage, the goal is to stimulate the smoker to think about the role smoking plays in her life, for the smoker to contemplate the benefits of quitting, and for the nurse to provide the smoker with information about the disadvantages of smoking (see Figure 2). During the contemplation stage, the goal is for a
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Part 1
Basics ¾ ¾ ¾
Assess stage of change Enhance client’s self awareness of smoking patterns Discuss health risks for woman and fetus
¾
Part 2 Stage-Matched Counseling
Precontemplation Increase thoughts of smoking patterns Discuss benefits of quitting Provide client with additional information ¾
Contemplation Identify personal benefits & barriers Make small changes in smoking ¾
¾
¾
Preparation Increase confidence that now is the time to quit Choose a cessation method & date Make small changes in smoking
Action Increase confidence that success is possible Identify tempting situations and alternatives Set a quit date Select people for social support Inform client of potential nicotine withdrawal
Maintenance Identify rewards for quitting Discuss healthy eating & exercise “Slip” management Potential postpartum resumption of smoking
Part 3
Additional Components Support Materials Living Smoke Free: A Healthier Start for You and Your Baby (booklet) The Feminine Mistake (video) Smoking and Pregnancy (ALA flip chart) Doppler for fetal heart tones
¾ ¾ ¾
Deep breathing and progressive relaxation Listening to fetal heart tones Second-hand smoke control plan
FIGURE 2
Smoke Free Families Program essentials.
smoker to identify the benefits and barriers to quitting and to get ready to quit by making small behavioral changes, such as reducing the number of cigarettes she smokes each day. During the preparation stage, the goal is for a smoker to increase her confidence that this is a 42 JOGNN
good time to quit, with the nurse assisting the smoker in developing a cessation plan. Strategies for the woman include beginning to think of herself as a nonsmoker, choosing a cessation method, setting a quit date, and making small changes in her smoking. During the action Volume 31, Number 1
stage, the goal is for the smoker to increase her confidence that she can be successful. The nurse helps the smoker acquire the requisite skills. Each smoker identifies situations in which she is tempted to smoke, creates alternatives to smoking, sets a quit date, identifies people for social support, and prepares for nicotine withdrawal symptoms. The goal for the woman who has quit but who does not yet identify herself as a nonsmoker is to maintain her quit status. Counseling strategies include encouraging the woman to reward herself for quitting and to continue a healthy lifestyle. The possibilities of occasional slips or postpartum resumption of smoking and strategies for continuing the quit attempt are discussed.
The First Home Visit The SFF program begins by identifying a woman as a tobacco user. The nurse, midwife, or physician advises her to quit and schedules the first home visit. During the first visit, the nurse assesses the woman’s stage of change and provides her with pregnancy-specific and stage-matched tobacco counseling as described above. For example, if
T
he SFF program is a useful adjunct to the Treating Tobacco Use and Dependence: Clinical Practice Guideline.
the woman is in the precontemplation stage, SFF counseling focuses on self-awareness of smoking patterns, information about health risks, advantages of cessation, and resources where the woman can find more information. The outcome desired is for the woman to begin thinking about quitting and continue through the other stages until she becomes a nonsmoker. Counseling is reinforced through the booklet, Living Smoke Free: A Healthier Start for You and Your Baby, which includes stagematched strategies (Boyd, Ershoff, & Quinn, 1996). Each woman is given this booklet, which includes a description of the health risks of smoking for women and fetuses. Women view segments of the videotape, the Feminine Mistake (David Bell Associates, 1989). In the first segment, the nicotine-induced peripheral vasoconstriction that occurs after a woman smokes a cigarette is demonstrated. In discussing the video, the nurse draws parallels between the demonstration and the effect that nicotine has on placental perfusion. In the second segment, an interaction between a physician and a pregnant woman during an ultrasound fetal evaluation is shown, and the effects of cigarette smoking on the fetus and newborn are discussed. The nurse expands on the information provided in the video, answers questions, and uses a flip chart to January/February 2002
illustrate physiologic effects of nicotine and carbon monoxide on the fetus (American Lung Association, 1982). Control of secondhand smoke in the home is part of the SFF program. The pregnant woman and nurse assess smoking in the home, problem-solve issues, and form a plan to eliminate or reduce smoking in the home. The health risks of secondhand smoke for children who live in the home and for the newborn are discussed. If family members are present, they are invited to join in the development of the plan. The nurse’s observation of the home helps in developing the secondhand smoke control plan. At the end of the visit, the pregnant woman identifies at least one counseling-related activity that she agrees to do before to the next home visit. Deep breathing and progressive relaxation exercises are practiced so that the visit ends with the woman feeling good (Pletsch, 1999). In addition, the woman is encouraged to use the exercises to manage stress during pregnancy and for relaxation during childbirth. The first visit typically lasts 45 minutes to an hour.
The Second Home Visit The second visit occurs 2 weeks later. The nurse and the pregnant woman evaluate the usefulness of the strategies the woman has used since the first visit. The nurse provides support and praise for the woman’s efforts. If the woman has moved to the next stage of change, new staged-matched counseling is provided. If the woman is at the same stage, activities are reviewed, reassessed, and revised. The woman and family members listen to fetal heart tones via Doppler, which enhances the woman’s awareness of the fetus, is enjoyable, and provides an opportunity for additional discussion of the effects of smoking on the fetus. The secondhand smoke control plan is reviewed and revised. The visit ends with deep breathing and progressive relaxation exercises. The second home visit lasts approximately 30 minutes.
Follow-Up For the duration of a woman’s pregnancy, the nurse conducts brief follow-up counseling with monthly telephone calls. Progress and pitfalls are assessed, and new plans are discussed. For women who quit smoking, the nurse discusses “slips,” occasions in which a person smokes a cigarette or two but remains in the action stage of quitting. Methods for avoiding postpartum resumption of smoking are discussed. These methods include anticipating tempting situations and avoiding them, being aware of the warning signs of smoking resumption, and shifting one’s focus to the benefits of not smoking. Women are encouraged to use the stress management skills developed while quitting, such as resting while the infant sleeps and asking for support from others.
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Models Integrating SFF Into Prenatal Care The ideal delivery format for the SFF program, based on focus group discussions with pregnant women, was as described above. Many obstetric practices, however, do not have the personnel or financial resources for home visiting (Dicky, Gemson, & Carney, 1999; Lia-Hoagberg, Schaffer, & Strochschein, 1999). The delivery method for the SFF program can be modified to fit the structure, resources, and philosophy of a practice by varying the health care providers who do the counseling, the clustering of program components, and the setting. Two such delivery modifications are described below.
Adaptations for Office-Based Counseling In this variation, a team approach is used to implement the guideline steps and the SFF program. For example, medical assistants or nursing staff screen women and document their tobacco use. Nurses, nurse-midwives, or physicians advise the woman to quit smoking. The SFF program is then implemented in 5- to 10-minute segments during regular prenatal visits. For example, the following activities can be implemented during separate visits by office staff: assess stage of change, provide stage-matched counseling, provide the woman with the booklet, assess secondhand smoke in the home, teach and practice deep breathing and progressive relaxation, show the video, discuss smoking-related health risks, and monitor progress. If available, a community outreach worker can assist the pregnant woman in developing the secondhand smoke control plan. Registered nurses can make the follow-up telephone calls or schedule time to meet with the woman during each prenatal visit. Documentation of assessments, counseling, and outcomes is available to team members in the woman’s medical record. The team approach requires good communication and documentation systems but results in tobacco control counseling being well integrated into prenatal care services. A disadvantage of counseling that is purely office based is that nurses are not able to directly assess and intervene regarding smoking activities in the home. For example, if a young pregnant woman lives with her parents who smoke, the home visit nurse can function as an advocate for the young woman in negotiating with parents to remove or reduce smoking in their home.
Coordination With Existing Nurse Home-Visiting Programs In the second variation, the office staff collaborates with the home-visiting staff of community organizations. Many communities have pregnancy-related home-visiting programs funded by local, state, or federal maternalchild/infant programs; health insurance companies; or nonprofit organizations. The SFF program can be delivered through the collaboration of office or clinic staff and 44 JOGNN
home-visiting nurses. In this delivery model, brief counseling, as recommended by the tobacco control guideline, is provided by office-based providers. When a woman is identified as a tobacco user, a referral, with her permission, is sent to a nurse in the home-visiting program.
T
he SFF program can be modified to fit the structure, resources, and philosophy of an obstetric practice by varying the personnel who provide the counseling, the clustering of program components, and the setting.
The SSF activities can be broken down into four to six sessions of 10 to 15 minutes each. The home-visiting nurse implements these shorter sessions as part of her regular visit. An example of a four-visit program follows. During the first home visit, the nurse assesses the woman’s stage of change and the secondhand smoke situation in the home. Deep breathing and progressive relaxation exercises are practiced. During the second visit, the video is viewed, smoking-related health risks are discussed, and the booklet is presented. During the third visit, stage-specific counseling takes place. During the fourth visit, the secondhand smoke plan is developed, fetal heart tones are heard, and the usefulness of activities is evaluated. At each subsequent home visit, the nurse provides support, reinforcement, and counseling. Communication between the home-visiting nurse and the office nurse about a woman’s progress is important. Ideally, electronic records make the visiting nurse’s notes available to the office staff, so they can reinforce the visiting nurse’s counseling and monitor the woman’s progress. In the absence of such electronic capability, notes can be sent via fax or mail. Thus, the office staff can implement the “arrange” guideline step through referral and monitoring of a woman’s tobacco use status. The SFF program is theoretically based and adaptable to a variety of delivery models. Tobacco control programs for pregnant women have been structured in various ways (Windsor & Boyd, 1998), including brief intervention as part of routine prenatal care (Ebrahim, Floyd, Merritt, Decoufle, & Holtzman, 2000; Windsor et al., 1993, 2000), group programs for pregnant women (Pletsch, 1995; Pohl & Caplan, 1998), multiple component programs (Ershoff, Mullen, & Quinn, 1989; Gebauer, Kwo, Haynes, & Wewers, 1998; Klerman & Rooks, 1999; Klesges, Ward, & DeBon, 1996; Pletsch, Devine, Payne, Volume 31, Number 1
& London, in press; Secker-Walker, Solomon, Flynn, Skelly, & Mead, 1998; Walsh, Redman, Brinsmead, Byrne, & Melmeth, 1997), and individual counseling (Orleans & Slade, 1993). The SFF program was designed to be consistent with the tobacco control guideline, be a more intensive adjunct to brief office-based counseling, and include assessment of the home environment. Nurses can develop a system in which the SFF program is used in conjunction with the Treating Tobacco Use and Dependence: Clinical Practice Guideline, selecting a delivery model that fits their clients, practice, and community.
Evaluation Strategies SFF Research The SFF program is being evaluated in two funded, longitudinal, randomized controlled trials with differing populations of pregnant women and their families. Women are randomized to treatment or usual care control conditions, and data are collected at preintervention, postintervention, and 36 weeks gestation. Variables include stage of change, processes of change, self-efficacy, family support, smoking status, and secondhand smoke exposure. The biologic marker of salivary cotinine is used to verify cessation. Although this evaluation is not yet complete, the components of the SFF program are well enough established for nurses to use it with their patients.
SFF Clinical Outcomes Evaluation Clinicians can evaluate the effectiveness of the SFF program with their patient populations by monitoring smoking-related outcomes. One category of outcomes is tobacco smoke exposure and includes documentation of the percentage of pregnant patients who reduce smoking, quit smoking, or create smoke-free households. This information can be recorded on the vital signs sheet at each prenatal visit (Fiore et al., 2000; Pletsch et al., in press). Perinatal complications is a second category of outcomes, but a large number of patients is required to be meaningful. Examples of such outcomes are rates of preterm labor and of births of small for gestation newborns (Nordentoft et al., 1996). The clinical evaluation process requires the establishing of monitoring and documentation systems, identifying of baseline rates for the outcomes selected, training of staff, implementing of the SFF program, and monitoring of changes in outcomes. Nurses can increase their contributions to the health of their pregnant clients and their clients’ families by integrating tobacco control counseling into prenatal care. With similar efforts by all who provide health care to pregnant women, we will move closer to the Healthy People 2010 goals.
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Acknowledgments This work was supported by grants from the National Institutes of Health (R15 NINR 04213) and the American Lung Association of Wisconsin. REFERENCES Ahluwalia, I. B., Grummer-Strawn, L., & Scanlon, K. S. (1997). Exposure to environmental tobacco smoke and birth outcome: Increased effects on pregnant women aged 30 years or older. American Journal of Epidemiology, 146(1), 42-47. American Lung Association. (1982). Smoking and pregnancy: Flip chart for health care providers (Publication No. 1/88 0432B). Milwaukee, WI: Author. Barber, K., Mussin, E., & Taylor, D. K. (1996). Fetal exposure to involuntary maternal smoking and childhood respiratory disease. Annals of Allergy Asthma and Immunology, 76, 427-430. Boyd, N. R., Ershoff, D., & Quinn, V. (1996). Living smoke free: A healthier start for you and your baby. San Bruno, CA: Krames Communications. Cancer Prevention Research Consortium. (1995). Pathways to health. Kingston: University of Rhode Island. Centers for Disease Control and Prevention. (2001). Women and smoking: A report of the surgeon general. Tobacco use and reproduction outcomes—fact sheet. Washington, DC: Author. Cnattingius, S., & Haglund, B. (1997). Decreasing smoking prevalence during pregnancy in Sweden: The effect on small-for-gestational-age births. American Journal of Public Health, 87, 410-413. Cook, D. G., & Strachan, D. P. (1999). Summary of effects of parental smoking on the respiratory health of children and implications for research. Thorax, 54, 357-366. David Bell Associates. (1989). The feminine mistake: The next generation. Santa Monica, CA: Pyramid Film & Video. DiClemente, C. C., Prochaska, J. O., Fairhurst, S. K., Velicer, W. F., Velasquez, M. M., & Rossi, J. S. (1991). The process of smoking cessation: An analysis of precontemplation, contemplation, and preparation stages of change. Journal of Consulting and Clinical Psychology, 59(2), 295-304. Dicky, L. L., Gemson, D. H., & Carney, P. (1999). Office system interventions supporting primary care-based health behavior change counseling. American Journal of Preventative Medicine, 17(4), 299-308. Ebrahim, S. H., Floyd, R. L., Merritt, R. K., Decoufle, P., & Holtzman, D. (2000). Trends in pregnancy-related smoking rates in the United States, 1987-1996. Journal of the American Medical Association, 283(3), 361-366. Ershoff, D. H., Mullen, P. D., & Quinn, V. P. (1989). A randomized trial of serialized self-help smoking cessation program for pregnant women in an HMO. American Journal of Public Health, 79, 182-187. Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Goldstein, M. G., Grtiz, E. R., et al. (1996). Smoking cessation: Clinical practice guideline (AHCPR Publication No. 96-
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0692). Rockville, MD: Agency for Health Care Policy and Research. Fiore, M. C., Bailey, W. C., Cohen, S. J, Dorfman, S. F., Goldstein, M. G., Grtiz, E. R., et al. (2000). Treating tobacco use and dependence: Clinical practice guideline. Washington, DC: U.S. Department of Health and Human Services, Public Health Service. Gebauer, C., Kwo, C. Y., Haynes, E. F., & Wewers, M. E. (1998). A nurse-managed smoking cessation intervention during pregnancy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 21, 47-53. Heinonen, S., Ryynanen, M., & Kirkinen, P. (1999). The effects on fetal development of high alpha-fetoprotein and maternal smoking. American Journal of Public Health, 89, 561-563. Klerman, L. V., & Rooks, J. P. (1999). A simple, effective method that midwives can use to help pregnant women stop smoking. Journal of Nurse Midwifery, 44, 118-123. Klesges, R. C., Ward, K. D., & DeBon, M. (1996). Smoking cessation: A successful behavioral/pharmacologic interface. Clinical Psychology, 16(6), 479-496. Li, J.S.M., Peat, J. K., Xuan, W., & Berry, G. (1999). Metaanalysis on the association between environmental tobacco smoke (ETS) exposure and the prevalence of lower respiratory tract infection in early childhood. Pediatric Pulmonology, 27, 5-13. Lia-Hoagberg, B., Schaffer, M., & Strochschein, S. (1999). Public health nursing practice guidelines: An evaluation of dissemination and use. Public Health Nursing, 16(6), 397-404. Lichtenstein, E. (1997). Behavioral research contributions and needs in cancer prevention and control: Tobacco use prevention and cessation. Preventive Medicine, 5 Pt 2, S57-S63. Mannino, D. M., Siegel, M., Husten, C., Rose, H., & Etzel, R. (1996). Environmental tobacco smoke exposure and health effects in children: Results from the 1991 National Health Interview Survey. Tobacco Control, 5, 13-18. Mullen, P. D. (1999). Smoking during pregnancy and intervention to promote cessation: A meta-analysis. Primary Care: Clinics in Office Practice, 26, 577-589. National Center for Health Statistics. (1998). Health, United States, 1998. With socioeconomic status and health chartbook. Hyattsville, MD: Author. Nordenberg, T. (1999). It’s quittin’ time—Smokers need not rely on willpower alone. FDA Consumer (Publication No. FDA 99-1288), 1-7. Nordentoft, M., Lou, H. C., Hansen, D., Nim, J., Pryds, O., Rubin, P., & Hemmingsen, R. (1996). Intrauterine growth retardation and premature delivery: The influence of maternal smoking and pyschosocial factors. American Journal of Public Health, 86, 347-354. NP Prescribing Reference. (2000). Vol. 7, No. 2. New York: Prescribing Reference Inc. Ogborn, P. L., Hurt, R. D., Croghan, I. T., Schroeder, D. R., Ramin, K. D., & Moyer, T. P. (1999). Nicotine patch use in pregnant smokers: Nicotine and cotinine levels and fetal effects. American Journal of Obstetrics and Gynecology, 181, 736-743. Oncken, C. A., Hardardottir, H., Hatsukami, D., Lupo, V., Rodis, J., & Smeltzer, J. (1997). Effects of transdermal
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nicotine or smoking on nicotine concentrations and maternal-fetal hemodynamics. Obstetrics & Gynecology, 90, 569-574. Oncken, C. A., Hatsukami, R. J., Lupo, V. R., Lando, H. A., Gibeau, L. M., & Hansen, R. J. (1996). Effects of shortterm nicotine gum use in pregnant smokers. Clinical Pharmacologic Therapy, 59, 654-661. Oncken, C. A., Pbert, L., Ockene, J. K., Zapka, J., & Stoddard, A. (2000). Nicotine replacement prescription practices of obstetric and pediatric clinicians. Obstetrics and Gynecology, 96(2), 261-265. Orleans, C. T., & Slade, J. (1993). Nicotine addiction: Principles and management. New York: Oxford University Press. Physician’s Desk Reference. (2000). Montvale, NJ: Medical Economics Company. Pletsch, P. K. (1995). Pregnant Hispanics: Smoke free madres, a smoking cessation intervention. Final report submitted to the American Lung Association of Wisconsin. Pletsch, P. K. (1999). Smoke Free Families: A smoking cessation program for pregnant African-American women. Final report submitted to the American Lung Association of Wisconsin. Pletsch, P. K., Devine, E. C., Payne, J., & London, R. (in press). Adoption of a smoking cessation guideline in primary care: A case study. Clinical Excellence for Nurse Practitioners. Pohl, J. M., & Caplan, D. (1998). Smoking cessation: Using group intervention methods to treat low-income women. Nurse Practitioner, 23(12), 13-39. Prochaska, J. O., & Velicer, W. F (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38-48. Secker-Walker, R. H., Solomon, L. J., Flynn, B. S., Skelly, J. M., & Mead, P. B. (1998). Reducing smoking during pregnancy and postpartum: Physician’s advice supported by individual counseling. Preventive Medicine, 27(3), 422430. U.S. Department of Health and Human Services. (1991). Healthy People 2000: National health promotion and disease prevention objectives. Washington, DC: Government Printing Office. U.S. Department of Health and Human Services. (2000a). Healthy People 2010 (conference edition, in two volumes). Washington, DC: Government Printing Office. U.S. Department of Health and Human Services. (2000b). Surgeon General’s report on smoking rates (press release). Atlanta, GA: CDC Office on Smoking and Health. Walsh, R. A., Redman, S., Brinsmead, M. W., Byrne, J. M., & Melmeth, A. (1997). A smoking cessation program at a public antenatal clinic. American Journal of Public Health, 87, 1201-1204. Windsor, R. A., & Boyd, N. R. (1998). A meta-evaluation of smoking cessation intervention research among pregnant women: Improving the science and art. Health Education Research, 13, 419-438. Windsor, R. A., Lowe, J. B., Perkins, L. L., Smith-Yoder, D., Artz, L., Crawford, M., et al. (1993). Health education methods for pregnant smokers: Its behavioral impact and cost benefit. American Journal of Public Health, 83, 201206.
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Windsor, R. A., Woodby, L. L., Miller, M., Hardin, J. M., Crawford, M. A., & DiClemente, C. C. (2000). Effectiveness of AHCPR practice recommendations and patient education methods for pregnant smokers in Medicaid maternity care. American Journal of Obstetrics & Gynecology, 182, 68-75. Wright, L. N., Thorp, J. M., Kuller, J. A., Shrewsbury, R. P., Ananth, C., & Hartmann, K. (1997). Transdermal nicotine replacement in pregnancy: Maternal pharmacogenetics and fetal effect. American Journal of Obstetrics & Gynecology, 176, 1090-1094.
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Pamela K. Pletsch is a professor in the School of Nursing, University of Wisconsin–Milwaukee. Sarah Morgan is a doctoral student in the School of Nursing, University of Wisconsin–Milwaukee. Address for correspondence: Pamela K. Pletsch, RN, PhD, P.O. Box 413, Milwaukee, WI 53201. E-mail: [email protected].
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