Using the 5A’s

Using the 5A’s

SIDS Mid-Atlantic presents

Presented by Health Care Education & Training, Inc. 2Created March 2002

SIDS Mid-Atlantic

2700 S. Quincy St. Suite 220 Arlington VA 22206 703-933-9100 www.sidsma.org [email protected] Betty Connal, RN, MS, Director


Objectives

To establish evidence-based, best practice prenatal smoking cessation interventions as a routine part of prenatal care by training health care providers in the Five A’s Method of Smoking Cessation

To assure that all pregnant women in Virginia are asked about their use of tobacco and that all pregnant smoking women in Virginia receive evidence-based treatments in smoking cessation


Program Objectives

Describe the 5A prenatal smoking cessation method

Incorporate the 5A prenatal smoking cessation method into the standard protocol

Identify readily available smoking cessation resources


Agenda

Introduction Ask Advise/Assess Assist/Arrange for follow-up Implementation issues and role play Resource identification Wrap-up


Risks of Smoking in Pregnancy

Smoking remains the single most important preventable cause of poor birth outcome

20% low birth weight deliveries

8% pre-term births

5% perinatal deaths


Risks of Smoking

Placenta previa Miscarriage Ectopic pregnancy Preterm Premature Rupture Of

Membranes Abruptio placenta


Risks of Smoking

Low birth weight Small for gestational age Preterm delivery 3 to 4 times greater risk of Sudden

Infant Death Syndrome (SIDS) Stillbirths


Smoking effects on the baby

Otitis media (ear infections) Asthma Bronchitis and pneumonia Wheezing and lower respiratory

illness


Who is at Risk for Premature Birth?

The best predictor of having a preterm birth is a history of preterm labor/delivery or prior low birthweight


Risk factors for premature birth

multifetal pregnancy—twins, triplets and more

maternal age (<17 and >35 years)

black race low SES unmarried previous fetal or neonatal

death 3+ spontaneous terminations uterine abnormalities incompetent cervix genetic predisposition


Risk for premature birth

low pre-pregnant weight obesity infections bleeding anemia major stress lack of social supports tobacco use illicit drug use alcohol abuse folic acid deficiency


Signs of Premature Labor

Contractions every 10 minutes or more Changes in vaginal discharge (leaking

fluid or blood from vagina) Pelvic pressure—baby pushing down Low dull backache Cramps that feel like a period Abdominal cramps with or without diarrhea


Why use the Five A’s?

About 35% of women will quit smoking during pregnancy, benefiting themselves, their next pregnancy, their children and their families


Cost of Complicated Births

Smokers average cost of birth $11,000

Non smokers average cost of birth $6500


Cost Effectiveness of Smoking Cessation Intervention Cost per life year saved, in thousands of

dollars Smoking Cessation Intervention $2500 Mammography $50,000 Treatment of high cholesterol $100,000


Timing of Health Benefits

1990 Surgeon General’s Report

20 minutesBlood pressure, heart rate return to

normal

8 hoursO2 level returns to normal; nicotine

and CO levels reduced by half

24 hoursCO is eliminated from body; lungs begin to eliminate mucus, debris

48 hoursNicotine eliminated from body; taste

and smell improve

72 hoursBreathing is easier; bronchial tubes

relax; energy levels increase

2 to 12 weeksCirculation improves

3 to 9 monthsLung function increases by up to

10%; coughing, wheezing, breathing problems reduced

1 yearHeart attack risk halved

10 yearsLung cancer risk halved

15 yearsHeart attack risk same as for someone who never smoked


Intervention Works

Smoking cessation intervention by clinicians improves quit rates

Brief counseling (5 to 15 minutes total) is all that is needed to help many pregnant smokers quit

A woman is more likely to quit smoking during pregnancy than at any other time in her life


The 5A approach

Ask about patient’s habits. Advise of consequence of

smoking. Assess willingness to quit. Assist with cessation plan

development. Arrange for follow-up


Research

Conclusions1. Brief cessation counseling session can

improve cessation rates as compared to simple advice to quit

2. More intensive counseling has not been documented to increase cessation rates

3. Benefits of brief counseling effective in light to moderate smokers (less than a pack per day)


Ask

A. I have NEVER smoked, or I have smoked less than 100 cigarettes in my lifetime.

B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.

Goal: Find out if patient smokes or has recently quit.


Ask (cont)

C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.

D. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant.

E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.


Advise

Goal is to either: 1) present compelling evidence about the

importance of quitting

2) encourage recent quitters to continue abstinence.

Message must be strong, clear, and relevant to specific patient’s concerns.


Advise Examples

Appropriate:“Ms. Smith, it is important for you to quit smoking.

As your Resource Mother, I need you to know that quitting smoking increases your chances of having a healthy baby. Your health will also improve...”

Inappropriate: “Ms. Smith, you need to quit smoking.”


Create an Advise Statement

Maria is 19-year old woman with two children. She has smoked since she was 16 years old. She has indicated that she smoked with her first two children and “they are fine.”


Advise example for recent non-smoker “Ms. Smith, I want to congratulate you on

making such an important decision for your baby’s health. As your nurse, I need you to know that quitting smoking has greatly increased your chances of having a healthy baby. Your health will also improve….”


Three patient types

Current smoker who wants to quit. Recent non-smoker Current smoker who does not want to quit.

Target of Assess step


Assess Decision Flow

YesDoes patient

currently smoke?

Patient willing to quit?

Provide appropriate cessation

techniques (Step 4 of 5A approach)

Yes

No

Provide motivational

materials and counseling


Assess Decision Flow (cont)

YesDoes patient

currently smoke?

Has patient smoked in the

past?

Assist with cessation

maintenance (Step 4 of 5A

approach)

No


Dealing with the resistant patient

1. Find out why patient doesn’t want to quit.

2. Emphasize risks of smoking.

3. Point out the rewards of quitting.

4. Discuss roadblocks and ways to overcome them.


Patients Who Decline to Quit: Using the 5 R’s

Relevance

Risks

Rewards

Roadblocks

Repetition


Assist

Why people smoke: Addicted to nicotine Enjoyment

Common triggers: After eating Social situations


Assist (cont)

Roadblocks: Friends all smoke Doesn’t really want to quit but feels should quit

Rewards: Clothes and breath will smell better Cough will go away


Assist: Coping Strategies

Why people smoke: Addicted to nicotine/Drink lots of water Enjoyment/Do something else enjoyable

Common triggers: After eating/Eat breath mint Social situations/Avoid situations where there’s

smoke


Assist: Coping Strategies (cont) Roadblocks:

Friends all smoke/Talk on phone instead of in person

Doesn’t really want to quit but feels should quit/Identify personal reasons to quit

Rewards: Clothes and breath will smell better/Wash all

clothing Cough will go away/Track number of coughing

bouts per day


Smoking Cessation Plan

Step 1. Identify why, common triggers, and major roadblocks.

Step 2. Identify rewards.Step 3. Establish a quit date.Step 4. Identify cessation method and

coping strategies.Step 5. Provide resources.


Arrange for follow-up

For patient who has remained smoke-free, offer congratulations.

For patient who has relapsed, return to Assist step in 5A approach.


Relapse Questions

What was the trigger? When did the relapse occur? What was going on in your life at the time of

relapse? Did you have a support person there? What techniques did you try to help you work

through the craving? Would you like to set another quit date?


Reimbursement

ICD-9-CM code 305.1 (tobacco use disorder, tobacco dependence)

AND CPT code 99401 (15-minute physician-provided

counseling) with modifier 25 as part of regular prenatal visit

OR CPT code 99211 (nurse counseling)


Resources

SIDS Mid-Atlantic www.sidsma.org Go to ‘Professionals’ ‘Stop Smoking Stop SIDS Program’ Links to state and national info and

resourcesMarch of Dimes

www.marchofdimes.com


Great Start 1-866-66StartInteractive Quitline for Pregnant Smokers


Resources

Smoke Free Families www.smokefreefamilies.org

National Partnership to Help Pregnant Smokers Quit www.helppregnantsmokersquit.org


Virginia Quit Line

1-800-QUIT NOW

Using the 5A’s

Documents

Transcript of Using the 5A’s