A Tobacco Cessation and Relapse Prevention Program Designed for use in a WIC Clinic

Jennifer Jordan, MPH

Lane County Public Health

Eugene, OR

Background

In Lane County Oregon, smoking rates during pregnancy have risen significantly since 2001 and are now higher than the state average (15.2% vs. 12.6%).

Smoking during pregnancy is the single most preventable cause of illness and death among mothers and infants.

Targeting Women…again

1940’s – 1950’s 1970’s – 1980’s 2007

Background

Low-income women and those with less than 12 years of education are more likely to smoke during pregnancy and have less access to cessation support.

Pregnancy is a unique “window of opportunity” to influence behavior change.

Background

Approximately 20-30% of women who smoke before pregnancy quit when they learn they are pregnant and an additional 20-30% quit after entering prenatal care.

Unfortunately, at least half of these women resume smoking within the first 6 months postpartum and 80% relapse within the first year postpartum.

The Women, Infants, and Children (WIC) program serves over 42% of all pregnant women in Lane County

Purpose

Quitting for Keeps aims to increase access to tobacco relapse prevention and cessation services among low-income pregnant and postpartum women utilizing WIC services.

This community-based participatory research project collaborated with WIC staff and clients to modify the traditional 5A’s cessation intervention to a briefer 3A’s model that was tailored for the WIC setting and more easily incorporated into a client’s visit.

Materials & Methods

Lane County Public Health partnered with the Oregon Research Institute (ORI) to tailor ORI’s 3A’s (Ask, Advise, & Arrange) brief cessation intervention model for the WIC setting (see diagram).

Askabout tobacco

use

Non-Smoker orQuit>12 months

Ex-SmokerQuit<12 months

Current Smoker

AdviseImportance of quitting; right

to choose

ArrangeInterested in quitting in the next 30 days?”

Done

Yes.Set a quit date,

offer Quit Line & resources.

No.“I can help when

you areready”

Congratulate. Affirm

decision to quit.

Does she have a plan to stay

quit?

Encourage planning, offer quit resources

to help.

Flow Chart

QFK Logic Model

Inputs• Funding –

Legacy grant & matched funds

• Staff time

• ORI expertise

• WIC staff support

• Existing cessation resources

Activities• Collect input from

WIC staff & clients

• Identify & incorporate existing resources

• Develop training & materials

• Implement training and interventions

• Evaluate access, effectiveness, and process

TargetsWIC Staff

Low-income pregnant and postpartum WIC clients

Short-Term Outcomes

WIC staff increased knowledge and confidence of the 3A’s cessation and relapse prevention techniques

Intermediate Outcomes

Increased access to cessation and relapse prevention services and support among low-income pregnant and postpartum women

Long-Term Outcomes

Higher quit rates and lower relapse rates for low-income pregnant and postpartum women

Inputs• Funding –

Legacy grant & matched funds

• Staff time

• ORI expertise

• WIC staff support

• Existing cessation resources

Activities• Collect input from

WIC staff & clients

• Identify & incorporate existing resources

• Develop training & materials

• Implement training and interventions

• Evaluate access, effectiveness, and process

TargetsWIC Staff

Low-income pregnant and postpartum WIC clients

Short-Term Outcomes

WIC staff increased knowledge and confidence of the 3A’s cessation and relapse prevention techniques

Intermediate Outcomes

Increased access to cessation and relapse prevention services and support among low-income pregnant and postpartum women

Long-Term Outcomes

Higher quit rates and lower relapse rates for low-income pregnant and postpartum women

Materials & Methods

Three focus groups were conducted with WIC clients and staff to identify opportunities and barriers to providing brief tobacco cessation and relapse prevention interventions.

The input was used to adapt resources and tools for staff and clients, including a staff training, fact sheets on tobacco use and pregnancy, and a Quitting for Keeps resource guide.

Materials & Methods

In a Quitting for Keeps training on the 3A’s brief intervention technique, we included strategies for dealing with defensive clients, motivating clients who have previously been unsuccessful, using nonjudgmental approaches, communicating the potential health effects of tobacco, and referring clients to community resources.

Materials & Methods

In November 2007, the counselors began incorporating the intervention in their client visits.

Additionally, a “Quit Information” workshop was available every three months that met clients’ class requirements to receive their WIC vouchers.

Materials & Methods

Clients responded to follow-up phone surveys at 6 weeks, 6 months, and 12 months post-intervention.

Reports summarizing the number of interventions completed, the number of quit dates set, and client satisfaction were shared and discussed with WIC counselors at their monthly staff meetings.

Results

3A’s Staff Training Results (pre/post) Knowledge scores increased from average of

52% to 83% (p < .05); confidence scores also increased, but not significantly (n=11)

Intervention Data: 327 women received the 3A’s 62% pregnant; 38% postpartum 84% were current smokers 17% (n=57) set a quit date during the

intervention

Results

6 Weeks Post-Intervention Survey: 60% (n=160) response rate 65% felt staff advice was useful; 55% reported

the materials were useful Of those who had not quit, 75% reported

trying to quit in the last six months and 58% reported they were seriously considering quitting in the next 30 days

Results

Preliminary 6 Month Post-Intervention Data: 46% response rate (n=45) 19% report cutting back and 20% report

quitting and remaining quit

Status of Women Receiving Intervention (n-327)

62%

38%

84%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Pregnant Postpartum Current Smoker Set Quit Date

Per

cen

t

Smoking Status at 6 weeks (n=120)

Regular Smoker,

44%

Smoke Once in Awhile,

35%

Quit, 21%

Lessons Learned

Systematic cessation and relapse prevention training among WIC staff can successfully increase counseling practices.

Periodic feedback on the effectiveness of smoking interventions and opportunities for input are important motivators for providers to implement cessation promotion and relapse prevention.

Challenges include: making the intervention a priority; attrition on follow-up surveys; client recruitment for the cessation support class; and staff turn over.

Acknowledgements

We would like to thank the Lane County WIC staff for their

invaluable support of Quitting for Keeps and the great work they

do every day. Thanks also to Ed Lichtenstein at ORI for his

advice and feedback. Quitting for Keeps was funded by a grant

from the American Legacy Foundation® and we’ve truly

appreciated the technical assistance and support provided by

Robin Scott and Scott Thomas. Additional thanks to Laura

Hammond, Connie Sullivan and Karen Gillette for their support,

assistance, and encouragement.