May 2008

Grant Results

SUMMARY

Project staff at the Dartmouth Medical School created, assessed and distributed Smoking Cessation for Pregnancy and Beyond, a multimedia educational tool to help health care practitioners treat tobacco dependence in pregnant women. It is based on the principles of the 5A's smoking cessation intervention (for a full description of this intervention, see the Appendix).

Key Results

  • More than 700 copies of the CD-ROM have been purchased since its release in October 2004. The program can be ordered online through the American College of Obstetricians and Gynecologists and also can be downloaded online through Dartmouth Medical School.

Key Findings

  • Clinicians who viewed the program increased their use of many recommended smoking cessation interventions with both pregnant and non-pregnant smokers. For example:
    • The percentage of pregnant smokers who received more than one type of assistance to help them quit increased from 10 percent to 47 percent.
    • The percentage of pregnant smokers for whom clinicians arranged follow-up increased from 0 to 33 percent.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $845,861 for this solicited project from February 2001 to January 2006.

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THE PROBLEM

Smoking remains the single most significant cause of poor pregnancy outcomes in the United States. Studies have found that about half of clinicians routinely identify pregnant smokers and advise them to quit, but fewer than one-fifth of clinicians offer patients help to quit (McPhillips-Tangum, Tobacco Control, 7 (Suppl.), 1998).

Strategies that can be used include:

  • Suggesting problem-solving methods and skills for quitting.
  • Providing support as part of the treatment.
  • Helping to arrange support among family, friends and co-workers.
  • Providing cessation education materials.

The June 2000 update of the Public Health Service's Smoking Cessation Clinical Practice Guideline advises health care providers to vigorously work with pregnant smokers to get them to quit. It urges clinicians to:

  • Offer extended counseling to pregnant smokers (exceeding the minimal advice to quit).
  • Offer smoking cessation interventions to pregnant smokers at the first prenatal visit and throughout the course of the pregnancy.
  • Consider pharmacotherapy if the pregnant woman is otherwise unable to quit and when the benefits of quitting are likely to outweigh the risks of the medications and the continued smoking.

In order to implement the guideline effectively, clinicians need to learn and practice the skills involved in counseling patients and create office systems that support cessation interventions. Interactive learning via a computer program or the Internet is a potentially time-effective way to achieve behavior change in clinicians, according to the project team.

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RWJF STRATEGY

The interactive tool described in this report complemented the efforts of RWJF's Smoke-Free Families program. See the Anthology chapter and the State of the Science capstone meeting report for more on the findings and results of that national program.

The National Partnership to Help Pregnant Smokers Quit in Chapel Hill, N.C., grew out of the dissemination of the research conducted through Smoke-Free Families. Formed in May of 2001, it is a coalition of some 60 diverse organizations working to improve the health of this and future generations by increasing the number of pregnant smokers who quit smoking. It has been supported by RWJF (ID#s 045257 and 053310) as part of the Smoke-Free Families program.

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THE PROJECT

From 2001 to 2006, project staff at the Dartmouth Medical School created, assessed and distributed Smoking Cessation for Pregnancy and Beyond, an interactive multimedia educational tool to help health care practitioners treat tobacco dependence in pregnant women. It is based on the 5A's smoking cessation intervention.

Creating the Multimedia Program

To create the program, the project worked with the Interactive Media Laboratory, part of the Department of Community and Family Medicine at Dartmouth Medical School. Since 1990, the laboratory has produced high-end interactive multimedia educational programs for both patients and health care providers.

A panel of outside experts on smoking cessation reviewed the content of the program. Staff at the American College of Obstetricians and Gynecologists (ACOG) also gave input on the content.

Assessing the Program in Clinical Practice

In the summer of 2004, six community-based medical practices in New Hampshire and Vermont participated in a pilot study to assess the impact of viewing the program on implementation of the 5 A's in busy practices. The practices included four OB/GYN clinics, a family practice and a rural health clinic.

The assessment included:

  • An audit of 591 patient charts to track documentation of the 5 A's. Each of the six practices reviewed approximately 50 patient charts prior to and three months after practice staff used the Smoking Cessation for Pregnancy and Beyond program.
  • A survey in which 19 clinicians in the practices reported their smoking cessation counseling procedures prior to and after viewing the educational program.
  • A survey of 48 health care providers (13 physicians and nurse practitioners, 17 registered nurses and 8 other clinical staff) in the participating practices about the usefulness and usability of the multimedia program. Some 73 percent completed the questionnaire.

Marketing and Distributing the Program

Staff at Dartmouth worked closely with the staff of the National Partnership to Help Pregnant Smokers Quit (National Partnership) and the Washington-based communications firm Porter Novelli (working under a contract with the National Partnership) to:

  • Develop an outreach plan.
  • Write press releases and fact sheets.
  • Create ads.
  • Contact women's health trade journals.
  • Send announcements on several listservs.
  • Create slide presentations describing the multimedia program for partnership members and Dartmouth staff to use when conducting training sessions around the country.
  • Arrange for continuing education credits to encourage clinicians to view the program.

ACOG also promoted the program to its members and contracted with Dartmouth to sell the CD-ROM ($25.00) through the online ACOG Bookstore.

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RESULTS

Project staff reported these results:

  • Smoking Cessation for Pregnancy and Beyond CD-ROM was completed. The program combines interactive patient simulations, real-life patient interviews, case discussions, mini-lectures, and learning activities and Web resources to teach the principles of the 5 A's smoking cessation intervention:
    • Ask—Systematically identify all tobacco users at every visit.
    • Advise—Strongly urge all tobacco users to quit.
    • Assess—Determine willingness to make a quit attempt.
    • Assist—Aid the patient in quitting.
    • Arrange—Schedule follow-up contact.

    For a full description of the program, see the Appendix.
  • Since its October 2004 release, 1530 copies of Smoking Cessation for Pregnancy and Beyond CD-ROM were distributed through ACOG. Many of these copies were ordered and distributed to state and county public health and perinatal health programs. In particular, the state of Missouri purchased 300 copies in 2005. The program is still available for download at no cost at the Interactive Media Laboratory Web site. The CD-ROM also can be purchased online through ACOG.
  • Members of the National Partnership to Help Pregnant Smokers Quit use the CD-ROM in their training programs.
    • Project staff at Dartmouth created a 50-minute module for medical students in OB/GYN and family practice that shows how to use the multimedia program in a classroom setting or as a self-directed learning tool.
      • Staff presented the module on May 16, 2005 as part of a one-day train-the-trainer session sponsored by the Boston-based Pace Project. Funded by the National Cancer Institute, the Pace Project is working with 12 U.S. medical schools to improve smoking cessation and prevention education for medical students.
    • Project Director Gaffney used the multimedia program to conduct two state-wide training programs in Maine and Kansas. Sixty-five people attended in Maine and 95 in Kansas.

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ASSESSMENT FINDINGS

Project staff reported these findings from the assessment of the program's impact at the six practices:

  • Clinicians who viewed the program increased the use of the 5 A's intervention with both pregnant and non-pregnant smokers.
    • Patient chart audits of a sample of 52 pregnant smokers showed an increase in the documentation of smoking status, patients being advised to quit and patients receiving assistance to quit. (Assistance included counseling the patient, giving education materials, arranging follow-up and other.)
      • Among pregnant smokers, documentation of smoking status increased from 95 percent to 100 percent of patients.
      • The percentage of smokers for whom clinicians arranged follow-up increased from zero to 33 percent.
      • The percentage of smokers who received more than one type of assistance increased from 10 to 47 percent.
      • The number of smokers being referred to a quitline rose from zero to three.
    • Chart audits of 134 other smokers, both pregnant and not pregnant, showed similar increases in arranging follow-up and providing more than one type of assistance.
      • Documentation of arranging follow-up rose from 2 percent to 21 percent.
      • Providing more than one type of assistance rose from 10 percent to 60 percent.
  • Clinicians and staff spent 2.5 hours, on average, using the program and its online resources, a significant investment of time, according to the project director. The staff questionnaire also found that the program:
    • Provided more than, or as much, information as staff needed to perform the 5A's.
    • Contained just the right amount of information for staff to implement comprehensive smoking cessation.
    • Was manageable to navigate and use.

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LESSONS LEARNED

  1. When working to translate findings from "bench to bedside," it is important to forge partnerships between researchers, health practitioners and communicators. The organizations that worked on the multimedia program to help pregnant smokers quit brought to the table the latest science on smoking cessation, practical experience in the trenches with patients, and relevant communication and marketing expertise. "If any of the groups had done this solo, what would we have now? I'm not sure," says C. Tracy Orleans, Ph.D. "That this was happening under the Partnership umbrella [The National Partnership to Help Pregnant Smokers Quit], that made it work. We needed to have a larger translational structure in place to get something like this out." (RWJF Program Officer/C. Tracy Orleans)
  2. Partner with highly skilled and experienced producers when creating multimedia programs. Multimedia technology changes rapidly, so choose companies that know the field well. (Project Director)
  3. Build in extra time to do the production of multimedia programs. Production was delayed because of the Interactive Media Laboratory's busy schedule, which also delayed the start of the evaluation in the practices. "Good programmers are hard to come by," cautions Gaffney. "Give yourself extra time." (Project Director)
  4. To reach a wide audience, an educational program needs champions. The close working relationship between the National Partnership to Help Pregnant Smokers Quit and ACOG meant that many people made presentations about the multimedia program and used it in a variety of training and education venues. This helped broaden the product's exposure. (Project Director)
  5. Being able to get continuing education credits does not appear to motivate clinicians to use multimedia programs. Very few clinicians signed up to get CECs, according to the project director, but they nonetheless spent an average of two hours working through the program. (Project Director)

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AFTER THE GRANT

Staff at Dartmouth hope to update Smoking Cessation for Pregnancy and Beyond to reflect changes in the smoking cessation practice guideline, which is scheduled for release in 2008.

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GRANT DETAILS & CONTACT INFORMATION

Project

Developing an Interactive Multimedia Program to Help Pregnant Patients Stop Smoking

Grantee

Dartmouth Medical School (Hanover,  NH)

  • Amount: $ 845,861
    Dates: February 2001 to January 2006
    ID#:  037958

Contact

Cecelia Carter Gaffney
(603) 653-3641
cecelia.gaffney@dartmouth.edu

Web Site

http://iml.dartmouth.edu/education/cme/Smoking

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APPENDICES


Appendix 1

Description of Smoking Cessation for Pregnancy and Beyond Multimedia Program

Smoking Cessation for Pregnancy and Beyond teaches the principles of the 5 A's of smoking cessation:

  • Ask—Systematically identify all tobacco users at every visit.
  • Advise—Strongly urge all tobacco users to quit.
  • Assess—Determine willingness to make a quit attempt.
  • Assist—Aid the patient in quitting.
  • Arrange—Schedule follow-up contact.

The program uses Interactive Media Laboratory's Virtual Clinic™ model, which combines interactive patient simulations, real-life patient interviews, case discussions, mini-lectures, learning activities and Web resources. In addition to teaching the principles of the 5 A's intervention, the interactive cases provide the learner an opportunity to address the broader psychosocial dimensions of smoking cessation counseling.

The creators of the multimedia program organized the teaching material by "rooms":

  • In Room A, the Examining Room, clinicians learn to use the 5A's with realistic simulated patients. Sharon Phelan, M.D., a practicing OB-GYN and a medical school educator, hosts the learner as she or he counsels and assists three simulated patients—a pregnant woman who is willing to quit, a pregnant woman who refuses to quit, and a woman who is not pregnant and is a smoker.
  • In Room B, "Counseling Demonstration," users sit in as an experienced physician applies the 5 A's with a patient.
  • In the Conference Room, "Case Discussions," Phelan discusses each simulated patient visit.
  • The Learning Resources Room features three "kiosks" that allow users to attend mini-lectures by smoking cessation experts, follow links to Web sites about smoking cessation, and view video interviews with real people who have quit smoking while pregnant.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Audio-Visuals and Computer Software

"Smoking Cessation for Pregnancy and Beyond: Learn Proven Strategies to Help Your Patients Quit." CD-ROM. Hanover, NH: Interactive Media Laboratory at Dartmouth Medical School, June 2004. Available for purchase online through the American College of Obstetricians and Gynecologists and free download online through Dartmouth Medical School.

Survey Instruments

Patient Exit Survey. Dartmouth Medical School, fielded 2004 to 2005.

Chart Audit Form. Dartmouth Medical School, fielded 2004 to 2005.

Clinician Survey. Dartmouth Medical School, fielded 2004 to 2005.

World Wide Web Sites

http://iml.dartmouth.edu/education/cme/Smoking. Home page for the interactive training program. Lebanon, NH: Interactive Media Laboratory at Dartmouth Medical School, 2004.

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Report prepared by: Kelsey Menehan
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans

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