- Email: [email protected]
Smoking-related activities in prenatal care programs
Smoking-Related Activities in Prenatal Care Programs Lorraine V. Klerman, DrPH, Crystal Spivey, DrPH Background: Convincing pregnant women who smoke to give up this behavior is one of the few universally agreed upon methods for improving pregnancy outcomes. An exploratory study was conducted to determine what public and quasi-public facilities serving pregnant women were doing to assist pregnant smokers in quitting, the reasons why more was not being done, and what could be done to increase smoking-cessation services. Methods:
Questionnaires eliciting information about pregnancy-related smoking prevention activities were mailed to home visitation projects, federally funded Healthy Start programs, CityMatCH members, and maternal and child health units in state health departments with a subsample of local health units. Responses were obtained from 354 programs.
Results:
Only about a quarter of the respondents thought they were doing enough to help pregnant smokers stop or reduce smoking, and most thought that the inadequacy was due to insufficient funds. Only about a quarter offered smoking-cessation classes or clinics. Almost all programs had policies restricting smoking in their offices. The nationally sponsored activity that the respondents felt might be most helpful in increasing their efforts was the provision of materials. Among the 313 programs that included home visits, 86% required the home visitors to conduct a needs assessment, and 97% of those expected the woman’s smoking status to be recorded. Smoking status prior to pregnancy or by other household members was required less often. Less than half of the programs provided training on smoking-cessation/reduction methods to home visitors. Only 28% said smoking-cessation/ reduction had a very high priority in comparison to other home visit objectives.
Conclusions: Programs for pregnant women, including those with a home visit component, do not pay sufficient attention to the problem of smoking among their clients. Programs should make greater use of the evidence-based interventions now available. (Am J Prev Med 2003;25(2):129 –135) © 2003 American Journal of Preventive Medicine
Introduction
C
onvincing pregnant women who smoke to give up this behavior is one of the few universally agreed upon methods for improving pregnancy outcomes. The U.S. Public Health Service’s publication, Treating Tobacco Use and Dependence, states that smoking by pregnant women is associated with stillbirths, spontaneous abortions, decreased fetal growth, premature births, low birth weight, placental abruption, sudden infant death syndrome, cleft palate and cleft lip, and childhood cancers.1 Moreover, evidencebased guidelines are now available to assist clinicians serving pregnant smokers in their attempts to encourage cessation,1,2 and several studies have shown that such smoking-cessation programs for pregnant smokers are cost effective.3,4 It would be expected, therefore, From the Heller School for Social Policy and Management, Brandeis University (Klerman), Waltham, Massachusetts; and Department of Pediatrics, School of Medicine, University of Alabama at Birmingham (Spivey), Birmingham, Alabama Address correspondence and reprint requests to: Lorraine V. Klerman, DrPH, The Heller School for Social Policy and Management, Brandeis University, P. O. Box 9110/MS 035, Waltham MA 02454-9110. E-mail: [email protected].
that all programs for pregnant women would give smoking-cessation activities a high priority. Although early attempts to integrate smoking activities into ongoing prenatal programs experienced difficulties and did not always report positive results,5,6 more recent studies have found that such activities can be successful even with low-income populations whose behaviors are often considered most difficult to change.7–9 Programs that offer home visiting as an adjunct to clinic-based care should have an increased probability of changing behaviors, because home visiting affords more time for the augmented psychosocial intervention now believed essential for success. In fact, four randomized trials of smoking interventions implemented through visits to the home have reported success.10 –13 This article reports the results of an exploratory study designed to determine the smoking-related activities in prenatal programs sponsored by a range of public and quasi-public organizations that serve low-income women. Its objective was to determine what these organizations were doing to assist pregnant smokers in quitting, the reasons why more was not being done, and what could be done to increase smoking-cessation
Am J Prev Med 2003;25(2) © 2003 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(03)00117-X
129
services. Particular emphasis was placed on activities conducted by home visitors because of the prior successes of such services.
Methods Study Design Letters and questionnaires were mailed to four groups of public and quasi-public organizations that the investigators believed offered prenatal care, through clinics or home visitation, especially to women from low-income households. These organizations included: (1) all home visitation sites participating in the dissemination project directed by Olds et al.14; (2) all federally funded Healthy Start projects in operation in winter 1999; (3) all members of CityMatCH, an organization of maternal and child health (MCH) units in urban health departments; and (4) MCH units in all 50 state health departments. The state MCH units were asked to complete the questionnaires themselves if they conducted home visitation programs; if they did not, they were requested to send the investigators a list of those agencies within the state that did conduct such programs. The questionnaire was sent to a random sample from the submitted lists.
Response Rate Follow-up letters were sent to all nonresponding agencies, and these were followed by phone calls in the case of the home visitation sites and the Healthy Start projects. The response rates were 21of 24 home visitation sites (88%), 76 of the 81 eligible Healthy Start sites (94%), 109 of the 139 CityMatCH agencies (78%), and 123 of the 214 in the random sample of local health units (58%). In addition, 25 of the state MCH units responded for themselves. This provided a total of 354 respondents.
ing-related counseling, worker training, educational materials, and the priority given to smoking-cessation/reduction. The investigators primarily focused on determining the smoking-cessation–related activities of prenatal programs, especially those involving home visitors. In addition, the investigators were interested in determining whether there were differences among the four programs’ range and intensity of smoking-related activities that might be a result of the differing emphasis given to such activities by the programs’ affiliated organizations: ●
●
● ●
The home visitation program trained all nurse home visitors in its dissemination sites, including a 3-hour session on techniques to reduce smoking among pregnant women. All Healthy Start projects were encouraged to conduct smoking-related activities by their sponsor, the federal Maternal and Child Health Bureau. (A detailed analysis of the Healthy Start projects’ activities has been published.15) During the 1990s, CityMatCH did not devote much attention to smoking during pregnancy. For several years, the Centers for Disease Control and Prevention financed a program within the Association of Maternal and Child Health Programs (AMCHP), the organization of state health department MCH units, to increase smoking-related activities in state and local health departments.16
Data Analyses Chi-square analysis was used to determine whether the differences among the types of organizations were statistically significant. Tables 1 to 4 show the significant chi-square values based on four degrees of freedom, and differences by organization type are noted in the text only when significant. The differences between the home visitation projects and the other four projects were also tested, and these differences are noted only in the text.
Responders The letters and the follow-up calls were directed to the agency director, unless there was some indication on the lists that another individual was responsible for the program being studied. The responses suggested that most individuals completing the questionnaire were agency or program directors and they were most often nurses or social workers.
Survey Instrument The investigators developed most of the questions, with a few taken from a survey of smoking-cessation programs in managed care organizations (copy available from LVK). The questionnaires varied slightly by group. Only those portions that were the same for all groups are reported here. The portion to be completed by all agencies, regardless of whether they did home visiting, asked whether the agency thought it was doing enough to help pregnant smokers quit or reduce smoking and about smoking-cessation classes or clinics, smoking policies, and possible types of assistance from a national office. Another portion was to be answered only by agencies that sent staff members or staff from agencies with which they contracted to visit pregnant women, including teenagers, and/or new mothers in their homes. The questions asked about the criteria for home visiting, risk assessments, smok-
130
Results The responses to the questionnaire suggested that the organizations had taken relatively limited steps towards addressing smoking among pregnant women. Moreover, there were relatively few differences by type of organization.
All Agencies All agencies were asked whether they were doing enough to help pregnant smokers stop or reduce their smoking. Only about one quarter (24%) of the respondents thought they were. Of the four types of projects, the home visitation sites were significantly more likely to state that they were doing enough. Those agencies that responded negatively were provided with a list of possible barriers to doing more. Over three fifths of the respondents agreed that insufficient agency funds (63.3%) and insufficient staff time (60.7%) were reasons. Competing agency priorities were checked by 46.9%; state MCH units and home visitation sites were most likely to give this reason, whereas local health
American Journal of Preventive Medicine, Volume 25, Number 2
Table 1. Responses from all agencies, project doing enough
Responses Project doing enough to help pregnant smokers If not, why not? Insufficient agency funds Insufficient staff time Competing agency priorities Clients have more important problems Absence of experts to train workers Staff doubts about changing behavior Lack of good materials Pregnant women reluctant to admit smoking Lack of models appropriate to setting
Total (Nⴝ354)
Home visitation sites (nⴝ21) % (n)
Healthy Start sites (nⴝ76) % (n)
City MatCH agencies (nⴝ109) % (n)
State health departments (nⴝ25) % (n)
Local health units (nⴝ123) % (n)
p value
24.0 (85)
71.4 (15)
18.4 (14)
23.9 (26)
12.0 (3)
22.0 (27)
⬍0.0001
63.3 (224) 60.7 (215) 46.9 (166) 44.9 (159) 32.2 (114) 31.6 (112) 28.5 (101) 23.2 (82) 21.5 (76)
57.1 (12) 42.9 (9) 71.4 (15) 7.1 (12) 42.9 (9) 14.3 (3) 28.6 (6) 14.3 (3) 28.6 (6)
51.3 (39) 52.6 (40) 57.9 (44) 46.1 (35) 39.5 (30) 32.9 (25) 31.6 (24) 29.0 (22) 25.0 (19)
67.0 (73) 63.3 (69) 48.6 (53) 42.2 (46) 21.1 (23) 32.1 (35) 23.9 (26) 24.8 (27) 18.4 (20)
76.0 (19) 64.0 (16) 76.0 (19) 40.0 (10) 40.0 (10) 32.0 (8) 12.0 (3) 20.0 (5) 16.0 (4)
65.9 (81) 65.9 (81) 28.5 (35) 45.5 (56) 34.2 (42) 33.3 (41) 34.2 (42) 20.3 (25) 22.0 (27)
NS NS ⬍0.0001 NS 0.041 NS NS NS NS
NS, not significant.
Table 2. Responses from all agencies: classes, policies, national help Home visitation sites (nⴝ21) Total % (n) Responses (Nⴝ354)
Am J Prev Med 2003;25(2) 131
Offer smoking cessation classes or clinics If yes, problems with attendance? Lack of encouragement from household members Lack of child care Long enrollment waiting list Limited/inconvenient hours Inconvenient locations Smoking policies Not allowed in offices or reception areas Not allowed in interview areas Not allowed in workers’ offices Possibly helpful national office activities Materials Manual of best practices Workshops at national and regional meetings Technical assistance Information on website Teleconferencing NA, not available; NS, not significant.
Healthy Start sites (nⴝ76) % (n)
City MatCH agencies (nⴝ109) % (n)
State health departments (nⴝ25) % (n)
Local health units (nⴝ123) % (n)
p value
26.6 (94) 77.4 (274) 66.4 (221)
4.8 (1) 0.0 (0) NA
23.7 (18) 86.8 (66) 50.0 (38)
35.8 (39) 72.5 (79) 63.3 (69)
28.0 (7) 68.0 (17) 100.0 (25)
23.6 (29) 91.1 (112) 72.4 (89)
0.029 ⬍0.0001 ⬍0.0001
54.1 (180) 43.5 (145) 37.5 (125) 28.2 (94)
NA NA NA NA
38.2 (29) 6.6 (5) 25.0 (19) 25.0 (19)
58.7 (64) 100.0 (109) 33.0 (36) 25.7 (28)
100.0 (25) 100.0 (25) 32.0 (8) 32.0 (8)
50.4 (62) 4.9 (6) 50.4 (62) 31.7 (39)
⬍0.0001 ⬍0.0001 0.002 NS
98.0 (347) 91.0 (322) 95.2 (337)
100.0 (21) 81.0 (17) 100.0 (21)
97.4 (74) 86.8 (66) 97.4 (74)
98.2 (107) 93.6 (102) 95.4 (104)
100.0 (25) 92.0 (23) 100.0 (25)
97.6 (120) 92.7 (114) 91.9 (113)
NS NS NS
76.6 (271) 71.2 (252) 53.1 (188)
90.5 (19) 85.7 (18) 57.1 (12)
80.3 (61) 84.2 (64) 61.8 (47)
72.5 (79) 62.4 (68) 47.7 (52)
64.0 (16) 68.0 (17) 52.0 (13)
78.1 (96) 69.1 (85) 52.0 (64)
NS 0.012 NS
43.8 (155) 43.2 (153) 24.0 (85)
33.3 (7) 52.4 (11) 19.1 (4)
52.6 (40) 46.1 (35) 22.4 (17)
42.2 (46) 46.8 (51) 33.9 (37)
32.0 (8) 68.0 (17) 28.0 (7)
43.9 (54) 31.7 (39) 16.3 (20)
NS 0.006 0.032
132 American Journal of Preventive Medicine, Volume 25, Number 2
Table 3. Responses from agencies conducting home visiting: policies
Responses Home visiting routinely for all clients Risk assessment for all clients Home visitors expected to record Pregnant women’s smoking Women’s pre-pregnancy smoking Household members smoking Home visitors expected to counsel pregnant smokers
Home visitation sites (nⴝ21) % (n)
Total (Nⴝ313)
Healthy Start sites (nⴝ64) % (n)
City MatCH agencies (nⴝ98) % (n)
State health departments (nⴝ24) % (n)
Local health units (nⴝ106) % (n)
p value
47.9 (150) 85.6 (268)
71.4 (15) 95.2 (20)
79.7 (51) 79.7 (51)
28.6 (28) 86.7 (85)
41.7 (10) 87.5 (21)
43.4 (46) 85.9 (91)
⬍0.0001 NS
97.1 (304) 72.8 (228) 68.7 (215) 79.6 (249)
100.0 (21) 90.5 (19) 76.2 (16) 95.2 (20)
98.4 (63) 57.8 (37) 54.7 (35) 75.0 (48)
93.9 (92) 71.4 (70) 67.4 (66) 81.6 (80)
100.0 (24) 70.8 (17) 66.7 (16) 83.3 (20)
98.1 (104) 80.2 (85) 77.4 (82) 76.4 (81)
NS 0.009 0.037 NS
NS, not significant.
Table 4. Responses from agencies conducting home visiting: training, materials, and priority
Responses Home visitor’s training During orientation On-the-job Supply staff with printed or other materials Priority of smoking cessation/reduction activities Very high Somewhat high Middle Somewhat low and very low NS, not significant.
Total (Nⴝ313)
Home visitation sites (nⴝ21) % (n)
Healthy Start sites (nⴝ64) % (n)
City MatCH agencies (nⴝ98) % (n)
State health departments (nⴝ24) % (n)
Local health units (nⴝ106) % (n)
42.5 (133) 70.9 (222) 88.2 (276)
71.4 (15) 61.9 (13) 100.0 (21)
42.2 (27) 81.3 (52) 75.0 (48)
39.8 (39) 71.4 (70) 88.8 (87)
41.7 (10) 70.8 (17) 87.5 (21)
39.6 (42) 66.0 (70) 93.4 (99)
NS NS 0.003
27.5 (86) 29.1 (91) 27.8 (87) 15.7 (49)
57.1 (12) 19.1 (4) 23.8 (5) 0.00 (0)
26.6 (17) 37.5 (24) 25.0 (16) 10.9 (7)
23.5 (23) 31.6 (31) 27.6 (27) 17.4 (17)
25.0 (6) 33.3 (8) 20.8 (5) 20.8 (5)
26.4 (28) 22.6 (24) 32.1 (34) 18.9 (20)
0.037 NS NS NS
p value
department sites were significantly less likely than home visitation sites to cite this reason. The fourth most common reason was “clients have more important problems” (44.9%), and the Healthy Start sites were significantly more likely to check this reason than were the home visitation sites. The fifth most frequently cited reason was the absence of experts to train workers (32.2%). The home visitation sites checked the latter most often, which is surprising because they were the group that probably had the most tobacco-specific training. Checked less frequently were staff doubts about their ability to change women’s behavior (31.6%); lack of good materials (28.5%); pregnant women’s reluctance to admit smoking (23.2%); and lack of models appropriate to their setting (21.5%) (Table 1). All agencies were asked whether they offered smoking-cessation classes or clinics. About a quarter (26.6%) did, but home visitation sites were the least likely to offer such services. Some organizations that offered classes or clinics noted that these were part of prenatal or parenting educational programs. Of those with classes or clinics, over three quarters (77.4%) reported problems with attendance; local health units and Healthy Start sites checked this problem most often. Respondents were provided with a list of reasons that they believed were responsible for attendance problems. Lack of encouragement from other household members was the reason checked most often (66.4%), and all state MCH respondents cited this reason. The remaining reasons were lack of child care (54.1%); long waiting lists for enrollment (43.5%); limited or inconvenient hours (37.5%); and inconvenient locations (28.2%). All respondents from the state MCH units checked the child care and waiting list boxes, all the City MatCH respondents checked the waiting list box, and local health units checked limited and inconvenient hours more often (Table 2). The agencies were queried about their smoking policies. Almost all (98.0%) did not allow smoking in offices or reception areas. Smaller percentages did not allow smoking in workers’ offices (95.2%) or in interview areas (91.0%) (Table 2). The questionnaire also suggested several activities that could be sponsored by a national office and might be helpful to the smoking-cessation/reduction services in the agency. The approach most favored was materials (76.6%), followed by manual of best practices (71.2%) and workshops at national and regional meetings (53.1%). Other activities, which were checked by a quarter to a half of the agencies, were technical assistance (43.8%); information on a website (43.2%); and teleconferencing with colleagues (24.0%). Home visitation and Healthy Start sites were more likely to want a manual of best practices, while state MCH units and home visitation sites were more likely to want a website and CityMatCH sites to want teleconferencing (Table 2).
Agencies Conducting Home Visiting Of the 354 responding sites, 313 reported that they did home visiting. The largest group of home visitors was paraprofessionals, although there was considerable use of nurses, especially in the home visitation sites. Almost half (47.9%) of these agencies stated that home visiting was conducted routinely for all clients, while the remainder only visited the homes of those considered at high risk. The home visitation and Healthy Start sites were more likely to conduct home visiting routinely, and City MatCH agencies were significantly less likely than home visitation sites to do so. Clients considered at high risk included those with medical or obstetrical problems or a history of such problems, substance abusers, teenagers, victims of domestic violence, smokers, and those with psychosocial problems. Most agencies (85.6%) required home visitors to conduct a risk assessment for all clients, but a few did not require risk assessments of any clients. Among those agencies that required visitors to complete a risk assessment form for all or some clients, almost all expected the woman’s present smoking status to be recorded (97.1%); however, smoking status prior to pregnancy and smoking status of other household members were recorded much less frequently (72.8% and 68.7%, respectively). The home visitation sites were most likely to record pre-pregnancy status, and the Healthy Start sites were least likely to record the smoking status of household members. Almost four fifths (79.6%) of the respondents expected their home visitors to counsel pregnant smokers about smoking (Table 3). Less than half (42.5%) of the respondents reported providing the home visitors with training on smokingcessation/reduction methods during their orientation period. City MatCH and local health unit sites were significantly less likely than home visitation sites to provide such training. Most agencies (70.9%) claimed to provide such training while the home visitors were on the job. Most agencies (88.2%) and all home visitation sites provided their home visitors with printed or other materials about smoking (Table 4). In comparison to other objectives of the home visits, only 27.5% of the respondents said that smokingcessation/reduction had a very high priority. The home visitation sites were most likely to check this ranking. The Healthy Start, City MatCH, and local health unit sites were significantly less likely than the home visitation sites to check this priority. An additional 29.1% of the respondents ranked smoking-cessation/reduction as a somewhat high priority and 27.8% as a middle-level priority. Only 15.7% ranked smoking-related activities as a somewhat or very low priority. No home visitation site gave smoking-related services a low priority (Table 4). Priorities that were considered higher than smoking-cessation/reduction activities included dealing with Am J Prev Med 2003;25(2)
133
client problems related to drug addiction or domestic violence.
Discussion The results of this exploratory study provide a somewhat discouraging view of the smoking-cessation activities of agencies that serve pregnant women. (Because agencies responding to the survey were probably more likely than those not responding to be conducting some smoking-related activities, the results reported here may overestimate smoking-related activities.) The results, however, are not surprising because several other studies have reported similar findings among primary care physicians,6,17 community health centers,18 and managed care organizations.19 But studies have also shown that organizations that realize the importance of smoking-cessation services can incorporate smoking education into their service delivery model. For example, Windsor et al.7 implemented effective programs in health department clinics. The reasons why limited attention was being paid to smoking-cessation activities by the public and quasipublic agencies that responded to the survey included the belief that the pregnant women whom they served had more important problems; a feeling that it was very difficult, if not impossible, to convince pregnant women to stop smoking; and lack of materials that would assist in these efforts. Another reason not studied may be the absence of strong pressure from the groups with which these agencies are affiliated to undertake smoking-cessation programs. Minimal staff training in smoking-cessation techniques is another indication of the low priority given to such activities. The home visitation sites, which probably provided the most intense home visiting services in this survey and had the most favorable responses overall, were the sites that dedicated the most resources to educating staff about how to help pregnant smokers. The fact that such a large percentage of the respondents felt that there were more important agency priorities or that clients had more important problems may reflect a lack of understanding about how major an impact smoking may have on the fetus and/or the effectiveness of current antismoking interventions. In a recent Educational Bulletin, the American College of Obstetricians and Gynecologists (ACOG) stated, “For pregnant women who smoke less than 20 cigarettes per day, the provision of a 5–15 minute, five step counseling session and pregnancy-specific educational materials increases cessation by 30 –70%.”2 Such reduction would contribute significantly to lowering the number of low-birth-weight infants. Other questionnaire responses indicated the need for assistance in developing smoking-related services. Experts to educate staff, pregnancy-specific smoking materials, manuals of best practices, and other educa134
tional adjuncts would probably be well received. In addition, changes in agency policies would help staff. For example, requiring that information be collected about pre-pregnancy smoking status and about the smoking status of other household members would provide information essential to effective counseling. Smoking education programs should be a required part of all orientation programs, and worker skills should be upgraded on a regular basis. Workers could also be informed that they should not be reluctant to discuss smoking with their clients. Barzilai et al.20 found that the patients of family physicians who were asked about their tobacco use or counseled about quitting were more likely to be satisfied with their physicians. As expected, there were differences in the level of concern and activities among the groups. In general, the home visitation sites gave smoking-related activities a higher priority and were more likely to conduct risk assessments for all clients, to counsel pregnant smokers, and to supply materials to clients. Despite the interest of their national office, the Healthy Start projects reported a low rate of counseling, little education during orientation, and a low priority for cessation/reduction activities. The responses of the City MatCH agencies, the state MCH units, and the local health units were similar to those of the Healthy Start projects on many of the questions.
Conclusions All individuals and groups serving pregnant women need to direct more effort to helping smokers quit. Two U.S. Surgeon General reports (Reducing Tobacco Use4 and Women and Smoking21), the U.S. Public Health Service’s Clinical Practice Guideline,1 the ACOG Educational Bulletin,2 the guidelines from the National Association of County and City Health Officials,22 and the action plan produced by the National Partnership to Help Pregnant Smokers Quit23 should provide both the impetus and the education essential for such effort. The U.S. Task Force on Community Preventive Services has recommended healthcare system–level interventions that are relevant to public and quasi-public facilities. These recommendations include provider reminders plus provider education and multicomponent patient telephone support.24 Clearly, more research is needed, not only about how to convince pregnant women to stop smoking but also about how to convince clinicians to use the methods known to be effective.25 Preparation of this article was made possible by grants from the Robert Wood Johnson Foundation (34684) and the federal Maternal and Child Health Bureau, U.S. Department of Health and Human Services (MCHJ 6040).
American Journal of Preventive Medicine, Volume 25, Number 2
References 1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville MD: U.S. Department of Health and Human Services, Public Health Service, June 2000. 2. American College of Obstetricians and Gynecologists. Smoking cessation during pregnancy. Educational Bulletin No. 260. Washington DC: American College of Obstetricians and Gynecologists, September 2000. 3. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26:577–89. 4. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 5. Kendrick JS, Zahniser C, Miller N, et al. Integrating smoking cessation into routine public prenatal care: the Smoking Cessation in Pregnancy Project. Am J Public Health 1995;85:217–22. 6. Ockene JK, Lindsay EA, Hymowitz N, et al. Tobacco control activities of primary-care physicians in the Community Intervention Trial for Smoking Cessation. Tob Control 1997;69(suppl):49 –56. 7. Windsor RA, Woodby LL, Miller TM, et al. Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in Medicaid maternity care. Am J Obstet Gynecol 2000;182:68 –75. 8. Manfredi C, Crittenden KS, Cho YI, et al. Minimal smoking cessation interventions in prenatal, family planning, and well-child public health clinics. Am J Public Health 2000;90:423–7. 9. Valanis B, Lichtenstein E, Mullooly JP, et al. Maternal smoking cessation and relapse prevention during health care visits. Am J Prev Med 2001;20: 1–8. 10. Sexton M, Hebel JR. A clinical trial of change in maternal smoking and its effect on birth weight. JAMA 1984;251:911–5. 11. Rush D, Ormet J, King J, Eiser JR, Butler NR. A trial of health education aimed to reduce smoking among pregnant women. Paediatr Perinat Epidemiol 1992;6:285–97. 12. Olds DL, Henderson CR Jr, Tatelbaum R, Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. Pediatrics 1986;77:16 –28.
13. Olds DL, Robinson J, O’Brien R, et al. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics 2002;110:486 –96. 14. Olds DL, Henderson CR, Tatelbaum R. Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics 1994;93:228 –33. 15. Klerman LV, Spivey C, Raykovich KT. Smoking reduction activities in a federal program to reduce infant mortality among high risk women. Tob Control 2000;9(suppl 3):51–5. 16. Association of Maternal and Child Health Programs. Vital links: the MCH role in tobacco control. Washington DC: Association of Maternal and Child Health Programs, December 1997. 17. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Prev Med 1998;27:720 – 9. 18. Zapka JG, Pbert L, Stoddard AM, et al. Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers. Am J Public Health 2000;90:78 –84. 19. Barker DC, Robinson LA, Rosenthal AC. A survey of managed care strategies for pregnant smokers. Tob Control 2000;9(suppl 3):46 –50. 20. Barzilai DA, Goodwin MA, Zyzanski SJ, Stange KC. Does health habit counseling affect patient satisfaction? Prev Med 2001;33:595–9. 21. U.S. Department of Health and Human Services. Women and smoking: a report of the Surgeon General. Atlanta GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. 22. National Association of County and City Health Officials. Program and funding guidelines for comprehensive local tobacco control programs. Washington DC: National Association of County and City Health Officials, 2001. 23. National Partnership to Help Pregnant Smokers Quit. Action plan. Chapel Hill NC: National Partnership to Help Pregnant Smokers Quit, May 2002. 24. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001:20(suppl 2):10 –15. 25. Ockene JK. Primary care-based smoking interventions. Nicotine Tob Res 1999;1(suppl 2):s189 –93.
Am J Prev Med 2003;25(2)
135
Questionnaires eliciting information about pregnancy-related smoking prevention activities were mailed to home visitation projects, federally funded Healthy Start programs, CityMatCH members, and maternal and child health units in state health departments with a subsample of local health units. Responses were obtained from 354 programs.
Results:
Only about a quarter of the respondents thought they were doing enough to help pregnant smokers stop or reduce smoking, and most thought that the inadequacy was due to insufficient funds. Only about a quarter offered smoking-cessation classes or clinics. Almost all programs had policies restricting smoking in their offices. The nationally sponsored activity that the respondents felt might be most helpful in increasing their efforts was the provision of materials. Among the 313 programs that included home visits, 86% required the home visitors to conduct a needs assessment, and 97% of those expected the woman’s smoking status to be recorded. Smoking status prior to pregnancy or by other household members was required less often. Less than half of the programs provided training on smoking-cessation/reduction methods to home visitors. Only 28% said smoking-cessation/ reduction had a very high priority in comparison to other home visit objectives.
Conclusions: Programs for pregnant women, including those with a home visit component, do not pay sufficient attention to the problem of smoking among their clients. Programs should make greater use of the evidence-based interventions now available. (Am J Prev Med 2003;25(2):129 –135) © 2003 American Journal of Preventive Medicine
Introduction
C
onvincing pregnant women who smoke to give up this behavior is one of the few universally agreed upon methods for improving pregnancy outcomes. The U.S. Public Health Service’s publication, Treating Tobacco Use and Dependence, states that smoking by pregnant women is associated with stillbirths, spontaneous abortions, decreased fetal growth, premature births, low birth weight, placental abruption, sudden infant death syndrome, cleft palate and cleft lip, and childhood cancers.1 Moreover, evidencebased guidelines are now available to assist clinicians serving pregnant smokers in their attempts to encourage cessation,1,2 and several studies have shown that such smoking-cessation programs for pregnant smokers are cost effective.3,4 It would be expected, therefore, From the Heller School for Social Policy and Management, Brandeis University (Klerman), Waltham, Massachusetts; and Department of Pediatrics, School of Medicine, University of Alabama at Birmingham (Spivey), Birmingham, Alabama Address correspondence and reprint requests to: Lorraine V. Klerman, DrPH, The Heller School for Social Policy and Management, Brandeis University, P. O. Box 9110/MS 035, Waltham MA 02454-9110. E-mail: [email protected].
that all programs for pregnant women would give smoking-cessation activities a high priority. Although early attempts to integrate smoking activities into ongoing prenatal programs experienced difficulties and did not always report positive results,5,6 more recent studies have found that such activities can be successful even with low-income populations whose behaviors are often considered most difficult to change.7–9 Programs that offer home visiting as an adjunct to clinic-based care should have an increased probability of changing behaviors, because home visiting affords more time for the augmented psychosocial intervention now believed essential for success. In fact, four randomized trials of smoking interventions implemented through visits to the home have reported success.10 –13 This article reports the results of an exploratory study designed to determine the smoking-related activities in prenatal programs sponsored by a range of public and quasi-public organizations that serve low-income women. Its objective was to determine what these organizations were doing to assist pregnant smokers in quitting, the reasons why more was not being done, and what could be done to increase smoking-cessation
Am J Prev Med 2003;25(2) © 2003 American Journal of Preventive Medicine • Published by Elsevier Inc.
0749-3797/03/$–see front matter doi:10.1016/S0749-3797(03)00117-X
129
services. Particular emphasis was placed on activities conducted by home visitors because of the prior successes of such services.
Methods Study Design Letters and questionnaires were mailed to four groups of public and quasi-public organizations that the investigators believed offered prenatal care, through clinics or home visitation, especially to women from low-income households. These organizations included: (1) all home visitation sites participating in the dissemination project directed by Olds et al.14; (2) all federally funded Healthy Start projects in operation in winter 1999; (3) all members of CityMatCH, an organization of maternal and child health (MCH) units in urban health departments; and (4) MCH units in all 50 state health departments. The state MCH units were asked to complete the questionnaires themselves if they conducted home visitation programs; if they did not, they were requested to send the investigators a list of those agencies within the state that did conduct such programs. The questionnaire was sent to a random sample from the submitted lists.
Response Rate Follow-up letters were sent to all nonresponding agencies, and these were followed by phone calls in the case of the home visitation sites and the Healthy Start projects. The response rates were 21of 24 home visitation sites (88%), 76 of the 81 eligible Healthy Start sites (94%), 109 of the 139 CityMatCH agencies (78%), and 123 of the 214 in the random sample of local health units (58%). In addition, 25 of the state MCH units responded for themselves. This provided a total of 354 respondents.
ing-related counseling, worker training, educational materials, and the priority given to smoking-cessation/reduction. The investigators primarily focused on determining the smoking-cessation–related activities of prenatal programs, especially those involving home visitors. In addition, the investigators were interested in determining whether there were differences among the four programs’ range and intensity of smoking-related activities that might be a result of the differing emphasis given to such activities by the programs’ affiliated organizations: ●
●
● ●
The home visitation program trained all nurse home visitors in its dissemination sites, including a 3-hour session on techniques to reduce smoking among pregnant women. All Healthy Start projects were encouraged to conduct smoking-related activities by their sponsor, the federal Maternal and Child Health Bureau. (A detailed analysis of the Healthy Start projects’ activities has been published.15) During the 1990s, CityMatCH did not devote much attention to smoking during pregnancy. For several years, the Centers for Disease Control and Prevention financed a program within the Association of Maternal and Child Health Programs (AMCHP), the organization of state health department MCH units, to increase smoking-related activities in state and local health departments.16
Data Analyses Chi-square analysis was used to determine whether the differences among the types of organizations were statistically significant. Tables 1 to 4 show the significant chi-square values based on four degrees of freedom, and differences by organization type are noted in the text only when significant. The differences between the home visitation projects and the other four projects were also tested, and these differences are noted only in the text.
Responders The letters and the follow-up calls were directed to the agency director, unless there was some indication on the lists that another individual was responsible for the program being studied. The responses suggested that most individuals completing the questionnaire were agency or program directors and they were most often nurses or social workers.
Survey Instrument The investigators developed most of the questions, with a few taken from a survey of smoking-cessation programs in managed care organizations (copy available from LVK). The questionnaires varied slightly by group. Only those portions that were the same for all groups are reported here. The portion to be completed by all agencies, regardless of whether they did home visiting, asked whether the agency thought it was doing enough to help pregnant smokers quit or reduce smoking and about smoking-cessation classes or clinics, smoking policies, and possible types of assistance from a national office. Another portion was to be answered only by agencies that sent staff members or staff from agencies with which they contracted to visit pregnant women, including teenagers, and/or new mothers in their homes. The questions asked about the criteria for home visiting, risk assessments, smok-
130
Results The responses to the questionnaire suggested that the organizations had taken relatively limited steps towards addressing smoking among pregnant women. Moreover, there were relatively few differences by type of organization.
All Agencies All agencies were asked whether they were doing enough to help pregnant smokers stop or reduce their smoking. Only about one quarter (24%) of the respondents thought they were. Of the four types of projects, the home visitation sites were significantly more likely to state that they were doing enough. Those agencies that responded negatively were provided with a list of possible barriers to doing more. Over three fifths of the respondents agreed that insufficient agency funds (63.3%) and insufficient staff time (60.7%) were reasons. Competing agency priorities were checked by 46.9%; state MCH units and home visitation sites were most likely to give this reason, whereas local health
American Journal of Preventive Medicine, Volume 25, Number 2
Table 1. Responses from all agencies, project doing enough
Responses Project doing enough to help pregnant smokers If not, why not? Insufficient agency funds Insufficient staff time Competing agency priorities Clients have more important problems Absence of experts to train workers Staff doubts about changing behavior Lack of good materials Pregnant women reluctant to admit smoking Lack of models appropriate to setting
Total (Nⴝ354)
Home visitation sites (nⴝ21) % (n)
Healthy Start sites (nⴝ76) % (n)
City MatCH agencies (nⴝ109) % (n)
State health departments (nⴝ25) % (n)
Local health units (nⴝ123) % (n)
p value
24.0 (85)
71.4 (15)
18.4 (14)
23.9 (26)
12.0 (3)
22.0 (27)
⬍0.0001
63.3 (224) 60.7 (215) 46.9 (166) 44.9 (159) 32.2 (114) 31.6 (112) 28.5 (101) 23.2 (82) 21.5 (76)
57.1 (12) 42.9 (9) 71.4 (15) 7.1 (12) 42.9 (9) 14.3 (3) 28.6 (6) 14.3 (3) 28.6 (6)
51.3 (39) 52.6 (40) 57.9 (44) 46.1 (35) 39.5 (30) 32.9 (25) 31.6 (24) 29.0 (22) 25.0 (19)
67.0 (73) 63.3 (69) 48.6 (53) 42.2 (46) 21.1 (23) 32.1 (35) 23.9 (26) 24.8 (27) 18.4 (20)
76.0 (19) 64.0 (16) 76.0 (19) 40.0 (10) 40.0 (10) 32.0 (8) 12.0 (3) 20.0 (5) 16.0 (4)
65.9 (81) 65.9 (81) 28.5 (35) 45.5 (56) 34.2 (42) 33.3 (41) 34.2 (42) 20.3 (25) 22.0 (27)
NS NS ⬍0.0001 NS 0.041 NS NS NS NS
NS, not significant.
Table 2. Responses from all agencies: classes, policies, national help Home visitation sites (nⴝ21) Total % (n) Responses (Nⴝ354)
Am J Prev Med 2003;25(2) 131
Offer smoking cessation classes or clinics If yes, problems with attendance? Lack of encouragement from household members Lack of child care Long enrollment waiting list Limited/inconvenient hours Inconvenient locations Smoking policies Not allowed in offices or reception areas Not allowed in interview areas Not allowed in workers’ offices Possibly helpful national office activities Materials Manual of best practices Workshops at national and regional meetings Technical assistance Information on website Teleconferencing NA, not available; NS, not significant.
Healthy Start sites (nⴝ76) % (n)
City MatCH agencies (nⴝ109) % (n)
State health departments (nⴝ25) % (n)
Local health units (nⴝ123) % (n)
p value
26.6 (94) 77.4 (274) 66.4 (221)
4.8 (1) 0.0 (0) NA
23.7 (18) 86.8 (66) 50.0 (38)
35.8 (39) 72.5 (79) 63.3 (69)
28.0 (7) 68.0 (17) 100.0 (25)
23.6 (29) 91.1 (112) 72.4 (89)
0.029 ⬍0.0001 ⬍0.0001
54.1 (180) 43.5 (145) 37.5 (125) 28.2 (94)
NA NA NA NA
38.2 (29) 6.6 (5) 25.0 (19) 25.0 (19)
58.7 (64) 100.0 (109) 33.0 (36) 25.7 (28)
100.0 (25) 100.0 (25) 32.0 (8) 32.0 (8)
50.4 (62) 4.9 (6) 50.4 (62) 31.7 (39)
⬍0.0001 ⬍0.0001 0.002 NS
98.0 (347) 91.0 (322) 95.2 (337)
100.0 (21) 81.0 (17) 100.0 (21)
97.4 (74) 86.8 (66) 97.4 (74)
98.2 (107) 93.6 (102) 95.4 (104)
100.0 (25) 92.0 (23) 100.0 (25)
97.6 (120) 92.7 (114) 91.9 (113)
NS NS NS
76.6 (271) 71.2 (252) 53.1 (188)
90.5 (19) 85.7 (18) 57.1 (12)
80.3 (61) 84.2 (64) 61.8 (47)
72.5 (79) 62.4 (68) 47.7 (52)
64.0 (16) 68.0 (17) 52.0 (13)
78.1 (96) 69.1 (85) 52.0 (64)
NS 0.012 NS
43.8 (155) 43.2 (153) 24.0 (85)
33.3 (7) 52.4 (11) 19.1 (4)
52.6 (40) 46.1 (35) 22.4 (17)
42.2 (46) 46.8 (51) 33.9 (37)
32.0 (8) 68.0 (17) 28.0 (7)
43.9 (54) 31.7 (39) 16.3 (20)
NS 0.006 0.032
132 American Journal of Preventive Medicine, Volume 25, Number 2
Table 3. Responses from agencies conducting home visiting: policies
Responses Home visiting routinely for all clients Risk assessment for all clients Home visitors expected to record Pregnant women’s smoking Women’s pre-pregnancy smoking Household members smoking Home visitors expected to counsel pregnant smokers
Home visitation sites (nⴝ21) % (n)
Total (Nⴝ313)
Healthy Start sites (nⴝ64) % (n)
City MatCH agencies (nⴝ98) % (n)
State health departments (nⴝ24) % (n)
Local health units (nⴝ106) % (n)
p value
47.9 (150) 85.6 (268)
71.4 (15) 95.2 (20)
79.7 (51) 79.7 (51)
28.6 (28) 86.7 (85)
41.7 (10) 87.5 (21)
43.4 (46) 85.9 (91)
⬍0.0001 NS
97.1 (304) 72.8 (228) 68.7 (215) 79.6 (249)
100.0 (21) 90.5 (19) 76.2 (16) 95.2 (20)
98.4 (63) 57.8 (37) 54.7 (35) 75.0 (48)
93.9 (92) 71.4 (70) 67.4 (66) 81.6 (80)
100.0 (24) 70.8 (17) 66.7 (16) 83.3 (20)
98.1 (104) 80.2 (85) 77.4 (82) 76.4 (81)
NS 0.009 0.037 NS
NS, not significant.
Table 4. Responses from agencies conducting home visiting: training, materials, and priority
Responses Home visitor’s training During orientation On-the-job Supply staff with printed or other materials Priority of smoking cessation/reduction activities Very high Somewhat high Middle Somewhat low and very low NS, not significant.
Total (Nⴝ313)
Home visitation sites (nⴝ21) % (n)
Healthy Start sites (nⴝ64) % (n)
City MatCH agencies (nⴝ98) % (n)
State health departments (nⴝ24) % (n)
Local health units (nⴝ106) % (n)
42.5 (133) 70.9 (222) 88.2 (276)
71.4 (15) 61.9 (13) 100.0 (21)
42.2 (27) 81.3 (52) 75.0 (48)
39.8 (39) 71.4 (70) 88.8 (87)
41.7 (10) 70.8 (17) 87.5 (21)
39.6 (42) 66.0 (70) 93.4 (99)
NS NS 0.003
27.5 (86) 29.1 (91) 27.8 (87) 15.7 (49)
57.1 (12) 19.1 (4) 23.8 (5) 0.00 (0)
26.6 (17) 37.5 (24) 25.0 (16) 10.9 (7)
23.5 (23) 31.6 (31) 27.6 (27) 17.4 (17)
25.0 (6) 33.3 (8) 20.8 (5) 20.8 (5)
26.4 (28) 22.6 (24) 32.1 (34) 18.9 (20)
0.037 NS NS NS
p value
department sites were significantly less likely than home visitation sites to cite this reason. The fourth most common reason was “clients have more important problems” (44.9%), and the Healthy Start sites were significantly more likely to check this reason than were the home visitation sites. The fifth most frequently cited reason was the absence of experts to train workers (32.2%). The home visitation sites checked the latter most often, which is surprising because they were the group that probably had the most tobacco-specific training. Checked less frequently were staff doubts about their ability to change women’s behavior (31.6%); lack of good materials (28.5%); pregnant women’s reluctance to admit smoking (23.2%); and lack of models appropriate to their setting (21.5%) (Table 1). All agencies were asked whether they offered smoking-cessation classes or clinics. About a quarter (26.6%) did, but home visitation sites were the least likely to offer such services. Some organizations that offered classes or clinics noted that these were part of prenatal or parenting educational programs. Of those with classes or clinics, over three quarters (77.4%) reported problems with attendance; local health units and Healthy Start sites checked this problem most often. Respondents were provided with a list of reasons that they believed were responsible for attendance problems. Lack of encouragement from other household members was the reason checked most often (66.4%), and all state MCH respondents cited this reason. The remaining reasons were lack of child care (54.1%); long waiting lists for enrollment (43.5%); limited or inconvenient hours (37.5%); and inconvenient locations (28.2%). All respondents from the state MCH units checked the child care and waiting list boxes, all the City MatCH respondents checked the waiting list box, and local health units checked limited and inconvenient hours more often (Table 2). The agencies were queried about their smoking policies. Almost all (98.0%) did not allow smoking in offices or reception areas. Smaller percentages did not allow smoking in workers’ offices (95.2%) or in interview areas (91.0%) (Table 2). The questionnaire also suggested several activities that could be sponsored by a national office and might be helpful to the smoking-cessation/reduction services in the agency. The approach most favored was materials (76.6%), followed by manual of best practices (71.2%) and workshops at national and regional meetings (53.1%). Other activities, which were checked by a quarter to a half of the agencies, were technical assistance (43.8%); information on a website (43.2%); and teleconferencing with colleagues (24.0%). Home visitation and Healthy Start sites were more likely to want a manual of best practices, while state MCH units and home visitation sites were more likely to want a website and CityMatCH sites to want teleconferencing (Table 2).
Agencies Conducting Home Visiting Of the 354 responding sites, 313 reported that they did home visiting. The largest group of home visitors was paraprofessionals, although there was considerable use of nurses, especially in the home visitation sites. Almost half (47.9%) of these agencies stated that home visiting was conducted routinely for all clients, while the remainder only visited the homes of those considered at high risk. The home visitation and Healthy Start sites were more likely to conduct home visiting routinely, and City MatCH agencies were significantly less likely than home visitation sites to do so. Clients considered at high risk included those with medical or obstetrical problems or a history of such problems, substance abusers, teenagers, victims of domestic violence, smokers, and those with psychosocial problems. Most agencies (85.6%) required home visitors to conduct a risk assessment for all clients, but a few did not require risk assessments of any clients. Among those agencies that required visitors to complete a risk assessment form for all or some clients, almost all expected the woman’s present smoking status to be recorded (97.1%); however, smoking status prior to pregnancy and smoking status of other household members were recorded much less frequently (72.8% and 68.7%, respectively). The home visitation sites were most likely to record pre-pregnancy status, and the Healthy Start sites were least likely to record the smoking status of household members. Almost four fifths (79.6%) of the respondents expected their home visitors to counsel pregnant smokers about smoking (Table 3). Less than half (42.5%) of the respondents reported providing the home visitors with training on smokingcessation/reduction methods during their orientation period. City MatCH and local health unit sites were significantly less likely than home visitation sites to provide such training. Most agencies (70.9%) claimed to provide such training while the home visitors were on the job. Most agencies (88.2%) and all home visitation sites provided their home visitors with printed or other materials about smoking (Table 4). In comparison to other objectives of the home visits, only 27.5% of the respondents said that smokingcessation/reduction had a very high priority. The home visitation sites were most likely to check this ranking. The Healthy Start, City MatCH, and local health unit sites were significantly less likely than the home visitation sites to check this priority. An additional 29.1% of the respondents ranked smoking-cessation/reduction as a somewhat high priority and 27.8% as a middle-level priority. Only 15.7% ranked smoking-related activities as a somewhat or very low priority. No home visitation site gave smoking-related services a low priority (Table 4). Priorities that were considered higher than smoking-cessation/reduction activities included dealing with Am J Prev Med 2003;25(2)
133
client problems related to drug addiction or domestic violence.
Discussion The results of this exploratory study provide a somewhat discouraging view of the smoking-cessation activities of agencies that serve pregnant women. (Because agencies responding to the survey were probably more likely than those not responding to be conducting some smoking-related activities, the results reported here may overestimate smoking-related activities.) The results, however, are not surprising because several other studies have reported similar findings among primary care physicians,6,17 community health centers,18 and managed care organizations.19 But studies have also shown that organizations that realize the importance of smoking-cessation services can incorporate smoking education into their service delivery model. For example, Windsor et al.7 implemented effective programs in health department clinics. The reasons why limited attention was being paid to smoking-cessation activities by the public and quasipublic agencies that responded to the survey included the belief that the pregnant women whom they served had more important problems; a feeling that it was very difficult, if not impossible, to convince pregnant women to stop smoking; and lack of materials that would assist in these efforts. Another reason not studied may be the absence of strong pressure from the groups with which these agencies are affiliated to undertake smoking-cessation programs. Minimal staff training in smoking-cessation techniques is another indication of the low priority given to such activities. The home visitation sites, which probably provided the most intense home visiting services in this survey and had the most favorable responses overall, were the sites that dedicated the most resources to educating staff about how to help pregnant smokers. The fact that such a large percentage of the respondents felt that there were more important agency priorities or that clients had more important problems may reflect a lack of understanding about how major an impact smoking may have on the fetus and/or the effectiveness of current antismoking interventions. In a recent Educational Bulletin, the American College of Obstetricians and Gynecologists (ACOG) stated, “For pregnant women who smoke less than 20 cigarettes per day, the provision of a 5–15 minute, five step counseling session and pregnancy-specific educational materials increases cessation by 30 –70%.”2 Such reduction would contribute significantly to lowering the number of low-birth-weight infants. Other questionnaire responses indicated the need for assistance in developing smoking-related services. Experts to educate staff, pregnancy-specific smoking materials, manuals of best practices, and other educa134
tional adjuncts would probably be well received. In addition, changes in agency policies would help staff. For example, requiring that information be collected about pre-pregnancy smoking status and about the smoking status of other household members would provide information essential to effective counseling. Smoking education programs should be a required part of all orientation programs, and worker skills should be upgraded on a regular basis. Workers could also be informed that they should not be reluctant to discuss smoking with their clients. Barzilai et al.20 found that the patients of family physicians who were asked about their tobacco use or counseled about quitting were more likely to be satisfied with their physicians. As expected, there were differences in the level of concern and activities among the groups. In general, the home visitation sites gave smoking-related activities a higher priority and were more likely to conduct risk assessments for all clients, to counsel pregnant smokers, and to supply materials to clients. Despite the interest of their national office, the Healthy Start projects reported a low rate of counseling, little education during orientation, and a low priority for cessation/reduction activities. The responses of the City MatCH agencies, the state MCH units, and the local health units were similar to those of the Healthy Start projects on many of the questions.
Conclusions All individuals and groups serving pregnant women need to direct more effort to helping smokers quit. Two U.S. Surgeon General reports (Reducing Tobacco Use4 and Women and Smoking21), the U.S. Public Health Service’s Clinical Practice Guideline,1 the ACOG Educational Bulletin,2 the guidelines from the National Association of County and City Health Officials,22 and the action plan produced by the National Partnership to Help Pregnant Smokers Quit23 should provide both the impetus and the education essential for such effort. The U.S. Task Force on Community Preventive Services has recommended healthcare system–level interventions that are relevant to public and quasi-public facilities. These recommendations include provider reminders plus provider education and multicomponent patient telephone support.24 Clearly, more research is needed, not only about how to convince pregnant women to stop smoking but also about how to convince clinicians to use the methods known to be effective.25 Preparation of this article was made possible by grants from the Robert Wood Johnson Foundation (34684) and the federal Maternal and Child Health Bureau, U.S. Department of Health and Human Services (MCHJ 6040).
American Journal of Preventive Medicine, Volume 25, Number 2
References 1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville MD: U.S. Department of Health and Human Services, Public Health Service, June 2000. 2. American College of Obstetricians and Gynecologists. Smoking cessation during pregnancy. Educational Bulletin No. 260. Washington DC: American College of Obstetricians and Gynecologists, September 2000. 3. Mullen PD. Maternal smoking during pregnancy and evidence-based intervention to promote cessation. Prim Care 1999;26:577–89. 4. U.S. Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 5. Kendrick JS, Zahniser C, Miller N, et al. Integrating smoking cessation into routine public prenatal care: the Smoking Cessation in Pregnancy Project. Am J Public Health 1995;85:217–22. 6. Ockene JK, Lindsay EA, Hymowitz N, et al. Tobacco control activities of primary-care physicians in the Community Intervention Trial for Smoking Cessation. Tob Control 1997;69(suppl):49 –56. 7. Windsor RA, Woodby LL, Miller TM, et al. Effectiveness of Agency for Health Care Policy and Research clinical practice guideline and patient education methods for pregnant smokers in Medicaid maternity care. Am J Obstet Gynecol 2000;182:68 –75. 8. Manfredi C, Crittenden KS, Cho YI, et al. Minimal smoking cessation interventions in prenatal, family planning, and well-child public health clinics. Am J Public Health 2000;90:423–7. 9. Valanis B, Lichtenstein E, Mullooly JP, et al. Maternal smoking cessation and relapse prevention during health care visits. Am J Prev Med 2001;20: 1–8. 10. Sexton M, Hebel JR. A clinical trial of change in maternal smoking and its effect on birth weight. JAMA 1984;251:911–5. 11. Rush D, Ormet J, King J, Eiser JR, Butler NR. A trial of health education aimed to reduce smoking among pregnant women. Paediatr Perinat Epidemiol 1992;6:285–97. 12. Olds DL, Henderson CR Jr, Tatelbaum R, Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. Pediatrics 1986;77:16 –28.
13. Olds DL, Robinson J, O’Brien R, et al. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics 2002;110:486 –96. 14. Olds DL, Henderson CR, Tatelbaum R. Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics 1994;93:228 –33. 15. Klerman LV, Spivey C, Raykovich KT. Smoking reduction activities in a federal program to reduce infant mortality among high risk women. Tob Control 2000;9(suppl 3):51–5. 16. Association of Maternal and Child Health Programs. Vital links: the MCH role in tobacco control. Washington DC: Association of Maternal and Child Health Programs, December 1997. 17. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Prev Med 1998;27:720 – 9. 18. Zapka JG, Pbert L, Stoddard AM, et al. Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers. Am J Public Health 2000;90:78 –84. 19. Barker DC, Robinson LA, Rosenthal AC. A survey of managed care strategies for pregnant smokers. Tob Control 2000;9(suppl 3):46 –50. 20. Barzilai DA, Goodwin MA, Zyzanski SJ, Stange KC. Does health habit counseling affect patient satisfaction? Prev Med 2001;33:595–9. 21. U.S. Department of Health and Human Services. Women and smoking: a report of the Surgeon General. Atlanta GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2001. 22. National Association of County and City Health Officials. Program and funding guidelines for comprehensive local tobacco control programs. Washington DC: National Association of County and City Health Officials, 2001. 23. National Partnership to Help Pregnant Smokers Quit. Action plan. Chapel Hill NC: National Partnership to Help Pregnant Smokers Quit, May 2002. 24. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med 2001:20(suppl 2):10 –15. 25. Ockene JK. Primary care-based smoking interventions. Nicotine Tob Res 1999;1(suppl 2):s189 –93.
Am J Prev Med 2003;25(2)
135