Making the Smoking Cessation Guideline a Routine Part of Prenatal Care
From April 2000 through September 2005, project staff at the American College of Obstetricians and Gynecologists (ACOG) spearheaded an effort to establish the U.S. Public Health Service's smoking cessation guideline (the 5 A's), published in 2000, as a routine part of prenatal care for all pregnant women in the United States.
- Developed a guide and toolkit to help physicians implement the smoking-cessation intervention in clinical practice.
- Worked with professional organizations to amend the medical school and the obstetrics and gynecological residency curricula to emphasize smoking-cessation interventions with pregnant women.
- Supported state-level groups in training clinicians.
The Robert Wood Johnson Foundation (RWJF) supported this unsolicited project with a grant of $749,568.
In 1999, the Centers for Disease Control and Prevention (CDC) reported that 21 percent of American women smoked during pregnancy (CDC report, 2002). According to the U.S. Surgeon General's 2001 report:
- The most effective way to protect the fetus is to quit smoking. A woman who quits within the first three or four months of pregnancy can lower the chances of a premature birth or a baby with health problems related to smoking.
- Smoking during pregnancy accounts for 20 to 30 percent of low-birthweight babies, as many as 14 percent of preterm deliveries and about 10 percent of all infant deaths.
5 A's: Best Practice for Smoking Cessation
In 2000, the U.S. Public Health Service (USPHS) published a best practice guideline for clinicians treating tobacco use and dependence, which includes pregnancy-specific information. The guideline is built around the 5 A's, a patient-centered model of behavioral counseling:
- Ask patients if they smoke.
- Advise them to quit with clear, strong and personalized messages.
- Assess their willingness to quit within 30 days.
- Assist them, if they are willing to quit, to develop a specific quit plan and provide practical and problem-solving counseling.
- Arrange for more help at subsequent offices visits, if needed.
Making a Difference
The American College of Obstetricians and Gynecologists (ACOG), with headquarters in Washington, is a nonprofit, professional educational organization that represents most of the nation's obstetricians and gynecologists (ob-gyns). ACOG actively promotes smoking-cessation interventions for women.
According to ACOG survey data, almost all ob-gyns ask their pregnant patients if they smoke and advise them to quit. Far fewer physicians take the next steps of assessing their patients' willingness to quit, assisting them and arranging for help.
When they do, the results are dramatic. According to a 2000 article in Tobacco Control (Melvin et al., 2000), physicians who spend five to 15 minutes counseling their pregnant patients and providing them with written self-help material can achieve 70 percent quit rates, compared to 30 percent for those who simply provide advice to quit.
In 1997, RWJF funded ACOG and four other large organizations of health care professionals to launch campaigns to inform their clinician members about the USPHS clinical practice guideline on smoking cessation and to help them integrate the interventions into their office practice. See Grant Results on ID# 030525 etc.
RWJF also created a national program called Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy (see Grant Results). The program has been working to discover the best ways to help pregnant smokers quit and to spread the word about effective evidence-based treatments.
RWJF also has funded the dissemination efforts of the National Partnership to Help Pregnant Smokers Quit with two grants (ID#s 045257 and 053310) totaling $1,927,600. The National Partnership is a coalition of 55 government and private organizations that seeks to improve the health of this and future generations by increasing the number of pregnant smokers who quit smoking.
Through a nationwide effort to reach women, providers and communities, the National Partnership hopes to ensure that all pregnant women in the Unites States are screened for tobacco use and receive best practice cessation counseling as part of their prenatal care.
In addition, RWJF has funded the Addressing Tobacco in Managed Care program that supported evaluations of replicable efforts by managed care organizations to integrate effective tobacco-cessation interventions into everyday clinical practice and the basic health care they provide. See the Grant Results on the program.
This project was designed to capitalize on:
- The May 2000 release of the updated USPHS smoking cessation guideline that outlined specific best practices for clinicians to use with women during their first pregnancy.
- Compelling new evidence about the harms and economic costs associated with smoking during pregnancy.
- Groundwork laid for best practice dissemination by ACOG and the Smoke Free Families program.
Project staff at ACOG had two grant objectives:
- Increase ob-gyn knowledge about the 5 A's smoking cessation intervention for pregnant women.
- Assure that the majority of obstetrician-gynecologists implemented the intervention as a routine part of prenatal care.
To achieve these objectives, staff:
- Measured knowledge and practice of smoking-cessation interventions by:
- Surveying 1,200 ob-gyns in Ohio in 2001. Smoke-Free Families and the Ohio Department of Health helped develop and disseminate the survey, which was administered by Princeton Survey Research Associates. More than 325 physicians responded.
- Surveying 5,000 ob-gyns nationwide in 2004. Princeton Survey Research Associates administered the survey. Smoke-Free Families provided $15,000 to oversample ob-gyns in 10 states.
- Conducting a focus group in Chicago in June 2005 with six ob-gyns. ACOG screened the ob-gyns to include those who deliver more than 100 babies per year and to represent different geographic areas and types of practices.
- Developed and disseminated educational tools to promote use of the 5 A's.
- Staff at Smoke-Free Families, the Association of Women's Health and Obstetric and Neonatal Nurses, the American College of Nurse-Midwives and other smoking cessation specialists provided guidance on content.
- Current Therapeutics, a medical information firm in Beachwood, Ohio, worked under a subcontract with ACOG to create the material.
- Partnered with the federal Maternal and Child Health Bureau, the Association of Maternal and Child Health Programs and Planned Parenthood, among others, to provide training and foster the involvement of other prenatal care providers in tobacco-cessation efforts. The Office on Smoking and Health and Division of Reproductive Health within the CDC provided additional support for some of these partnerships through a grant to the Association of Maternal and Child Health Programs.
- Promoted systems changes in medical training to foster adoption of the 5 A's through joint efforts with the Association of Professors of Gynecology and Obstetrics and the National Partnership to Help Pregnant Smokers Quit, supported in part by RWJF.
See Results for details on educational and training materials produced and partnership activities.
See Appendix 1 for information about dissemination.
To oversee its activities on prenatal smoking cessation, ACOG formed a 12-member advisory committee, including ACOG members and liaisons from Smoke-Free Families and the Association of Women's Health and Obstetric and Neonatal Nurses.
ACOG reported the following project results, as of September 2005:
- ACOG staff published "Smoking Cessation During Pregnancy" as a stand-alone bulletin and also in Obstetrics & Gynecology. Initially published in September 2000, and updated in the October 2005 issue of the journal, these documents:
- Established the 5 A's as a recommended part of prenatal care.
- Outlined the components of appropriate smoking-cessation counseling for pregnant women.
- Included a chart insert that guides the clinician through the steps of the 5 A's.
- ACOG staff developed a free toolkit for clinicians and office administrators. The kit, titled Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, includes:
- A 28-page monograph on how to integrate the 5 A's into routine prenatal care with various easy-to-copy office tools. Continuing medical education (CME) credits are available for answering questions in the back of the monograph.
- A 20-page case studies booklet that provides dialogue and key points to consider when counseling women who smoke.
- "Need Help Putting Out That Cigarette?"—a patient education workbook and CD-ROM.
The above three items, produced and provided by the Smoke-Free Families national dissemination office, are available in English and Spanish.
- A 40-slide lecture and lecture notes that outline the 5 A's intervention and how to integrate it into routine prenatal care.
- "How to Ask About Smoking Status," a laminated, quick-reference pocket card for clinicians produced by the Smoke-Free Families national dissemination office.
- "Smoking Cessation During Pregnancy," an ACOG educational bulletin.
ACOG staff disseminated these educational tools through direct mailings, Web site listings, promotions by affiliated groups, and distribution at national and local meetings.
Partnerships and Training
- ACOG developed partnerships between its state leaders and community and public-sector organizations involved with tobacco control and perinatal care. The goals were to train clinicians and develop other strategies for delivering the 5 A's to pregnant smokers. The lecture slides and monograph served as basic training materials.
- In 2005, ACOG awarded eight $1,000 minigrants to projects to support perinatal tobacco-cessation efforts at the state level. See Appendix 2.
- ACOG signed a cooperative agreement with the federal Maternal and Child Health Bureau to develop tobacco-centered partnerships in five states: Maryland, Nevada, New Jersey, New York and North Carolina.
- Through collaboration with the Association of Maternal and Child Health Programs and Planned Parenthood, ACOG developed 10 additional state teams in Colorado, Hawaii, Iowa, Louisiana, Minnesota, Missouri, North Dakota, Ohio, Pennsylvania and Wisconsin.
- As part of its 2004–09 Prematurity Campaign, the March of Dimes directed all of its chapters to undertake at least one activity focused on increasing perinatal provider use of the 5 A's in 2004–05. Some 28 March of Dimes chapters provided training at grand rounds and other venues, generally using the ACOG lecture notes and slides. March of Dimes staff distributed 2,700 toolkits at these events.
To institutionalize the 5 A's as part of routine prenatal care, ACOG staff:
- Met with representatives of the Association of Professors of Gynecology and Obstetrics, which led to changes in the medical school curriculum. As of 2005, medical students are required to:
- List factors contributing to the greater difficulty adolescent girls and women have in quitting tobacco use.
- Provide resources to help girls and women quit smoking.
- List the known consequences of tobacco use during the reproductive years.
- List factors that predict successful smoking cessation during pregnancy and throughout the life span.
- Assessed and recommended changes to the ob-gyn residency curriculum. As of 2005, the Council on Resident Education in Obstetrics and Gynecology of the ACOG had added questions to the residency in-service ob-gyn exam that included questions on the 5 A's.
- Added a section on tobacco use to Précis: Primary and Preventive Care. The association's Précis publication series provides ob-gyns with the most up-to-date methods and techniques of clinical practice. See the Bibliography for details.
- Worked with the National Partnership to Help Pregnant Smokers Quit, a coalition of 55 government and private organizations, to improve Medicaid reimbursement for smoking-cessation treatment in prenatal care. According to a 2005 survey of state Medicaid program directors (reported in the November 10, 2006, issue of the CDC's MMWR), 42 states reported Medicaid coverage:
- Some 38 state Medicaid programs covered some tobacco-dependence treatment for all Medicaid recipients. Of these states, "all covered some type of medication treatment, including generic bupropion hydrochloride or Zyban® (36 states), nicotine nasal sprays (28 states), nicotine inhalers (28 states), nicotine patches (33 states), and nicotine gum (31 states)."
- Four states reported that they offered coverage only for pregnant women.
- One state (Oregon) offered coverage for all medication and counseling treatments recommended by the 2000 PHS guideline.
- Seven states (including Oregon) covered all recommended medications and at least one form of counseling.
- A total of 14 states offered some form of tobacco-cessation counseling services for their entire Medicaid population, and 12 additional states offered counseling services only for pregnant women.
- From 2003 to 2005, one state (Arkansas) added coverage for counseling of all Medicaid beneficiaries, one state (New Mexico) added coverage for counseling of pregnant women, and two states (North Dakota and Wisconsin) expanded existing counseling coverage.
- ACOG planned to update its Prenatal Record form, which most practicing ob-gyns use in their offices, to improve documentation of smoking status throughout the perinatal period, by the end of 2006.
ACOG Ohio Survey
In 2001, ACOG fielded a survey to more than 1,200 ob-gyns in Ohio. It assessed knowledge of smoking-cessation methods during pregnancy and barriers to integrating the 5 A's intervention into routine clinical practice.
According to an article by the project director in Nicotine & Tobacco Research (see the Bibliography for details):
- The 346 Ohio obstetricians who responded routinely asked their prenatal patients about smoking and advised them to quit. They were less likely to assess the patient's willingness to quit, to provide social support or pregnancy-specific education materials at the office, or to help the patient arrange social support at home.
- Three-fourths of the respondents reported having no formal training in smoking cessation. They were eager to learn more about:
- How to advise pregnant women to quit.
- How to provide social support.
- How to help their patients get social support at home or work.
- How to obtain patient education materials.
- How to organize their offices to provide smoking cessation counseling.
ACOG National Survey
ACOG staff surveyed 5,000 ob-gyns in 2004 to evaluate the impact of its strategies to improve awareness and implementation of the 5 A's.
Preliminary findings indicated that physicians had not implemented the 5 A's office protocols to the degree expected. As of the fall of 2006, project staff was analyzing the data and planned to publish an article on the results.
ACOG Focus Group
Staff members held a focus group with six ob-gyns in Chicago in June 2005 to explore obstacles to implementing the 5 A's. They reported the following findings to RWJF:
- Ob-gyns were moderately concerned about the effects of smoking on their pregnant patients. Focus group participants stated that their patients know the general hazards of smoking and those who take them seriously will quit; others will "try" but typically will not quit.
- Participants reported widely varying rates of success at getting their pregnant patients to quit smoking. Most felt their patients were honest with them about whether or not they quit.
- Regardless of their degree of success, the participants felt they are already doing everything possible to help patients quit. However, none of the participants was using the kind of patient-centered counseling approach that the 5 A's represents.
- Their use of pharmacotherapy, particularly Zyban, was mixed. Pharmacotherapy is not recommended for routine use in pregnancy. While a few used it as a last resort, others avoided it because they were concerned about risks to both mother and baby.
- None of the physicians knew about the toolkit available from ACOG prior to participating in the focus group.
- Among the components of the toolkit, the patient education workbook ("Need Helping Putting Out That Cigarette?") received the most attention, followed by the pocket card ("How to Ask About Smoking Status"). The physicians considered the full toolkit too lengthy and remarked that front office staff rarely gives them mail of that nature and size.
- The participants stated that time was their greatest barrier to implementing the changes suggested in the toolkit.
Participants made the following suggestions for improving smoking-cessation materials:
- Materials must be brief, positive and actionable. They should emphasize that the counseling approach may make the difference between patients who continue to smoke and those who quit.
- Messages should address what obstetricians can do with patients who "don't want to quit" versus patients who "want to quit but can't."
- Giving CME credits could have some impact, but only if a significant number are offered.
- Providing information about insurance coding and reimbursement for smoking-cessation counseling would have only minimal impact on practice.
- Reaching ob-gyns with educational information on smoking cessation in pregnancy requires persistence and multifaceted approaches. "Sending out materials to doctor's offices is not enough by itself," says Project Director Janet Chapin. "You need the Web; you need training; you need many approaches." (Project Director)
- Information for providers needs to be as short as possible but solidly backed by evidence. Obstetricians think it is their responsibility to deal with smoking, but they also think they already know how to do it. (Project Director)
- Ob-gyns are more apt to provide counseling, such as the 5 A's, when they have a script to follow. "Doctors think that if you tell patients what to do, they will do it. But they need to do more than that," says Project Director Chapin. "Behavioral interventions are not complicated, but they do require steps." (Project Director)
- Mailing toolkits to an ob-gyn's office does not guarantee that the physician will receive the information, even if it comes from professional organizations. "The materials may reach nurses in an office, which is not bad, but it is not what we intended," says Chapin. (Project Director)
- People who request the smoking cessation toolkit from the ACOG Web site are often training large groups. Contacting people ordering materials directly has allowed ACOG to disseminate large amounts of material to targeted audiences. (Project Director)
- State-level organizations know the best ways to disseminate information on smoking cessation in pregnancy to providers in their states. Supporting and joining state-based efforts are efficient ways to disseminate materials. (Project Director)
- Few physicians actually apply for continuing medical education credits. They may find easier ways to get CMEs, such as attending grand rounds. (Project Director)
AFTER THE GRANT
ACOG staff continues to showcase its educational and training materials at professional meetings and receives about 600 requests per month for copies. Staff members also serve on working committees of Smoke-Free Families and the National Partnership to Help Pregnant Smokers Quit.
As of September 2006, ACOG staff is pursuing these new or ongoing initiatives:
- With the American Academy of Pediatrics, promoting a seamless transition of a smoking-cessation message from obstetrical to infant care.
- With the Association of Maternal and Child Health Programs and Planned Parenthood, supporting 12 active state tobacco partnership teams that provide training in the 5 A's and help disseminate the toolkit.
- With the National Partnership to Help Pregnant Women Smokers Quit, supporting efforts to increase reimbursement for tobacco-cessation services during prenatal care and research for best cessation treatment and pharmacotherapy use during pregnancy.
GRANT DETAILS & CONTACT INFORMATION
Disseminating the Best Practice Intervention for Smoking Cessation During Pregnancy
American College of Obstetricians and Gynecologists (Washington, DC)
Dates: April 2000 to September 2005
Janet Chapin, R.N., M.P.H.
Dissemination of Educational Materials
Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking. As of September 2004:
- Printed 37,000 and distributed 27,000 toolkits, including to more than 17,000 ACOG members who provide prenatal care. In addition:
- Distributed 700 single copies of the monograph on integrating the 5 A's into prenatal care.
- Distributed 8,000 "Need Help Putting Out That Cigarette?" patient education workbooks and CD-ROMs free to public health agencies; 40,000 were purchased at a reduced rate.
- Distributed 600 slide lectures and lecture notes.
- Distributed 900 "How to Ask About Smoking Status" quick-reference pocket cards.
Smoking Cessation During Pregnancy (ACOG Education Bulletin No. 260). Obstetrics & Gynecology, September 2000.
- Total journal subscribers: 50,000.
- Staff fulfilled some 6,500 requests for copies from state health departments and nonprofit groups for use in training and other educational activities.
- Included in 37,000 training toolkits for physicians.
Smoking Cessation During Pregnancy (Committee Opinion No. 316). Obstetrics & Gynecology, October 2005.
- Distributed to 500 maternal and child health public health professionals.
Tobacco Partnership State Projects Supported by Minigrants
During the spring and summer of 2005, ACOG provided $1,000 minigrants to support the following activities:
Colorado Women's Tobacco Cessation Team
Funds were used to print and mail materials to promote the state's Prematurity Awareness Conference.
IOWA Women Against Nicotine and Tobacco (IWANT)
Funds supported a "lunch and learn" training in November 2005 for health care providers implementing a tobacco-cessation system-level change.
Minnesota State Team for Tobacco Cessation and Prevention for Women of Childbearing Age, including Pregnant Women
Funds helped support a one-day training on women and smoking cessation in January 2006. The training was available statewide via video conferencing to primary care practitioners, nurses, health educators, nutritionists, doulas (lay women who help with pregnancy and labor) and community health workers who provide services to pregnant women.
Nevada Tobacco-Free Babies Coalition
Funds were used to purchase 600 canvas tote bags as an incentive for pregnant women who quit smoking and remain tobacco free.
North Dakota Tobacco Partnership
Funds were used to print and distribute tobacco-cessation prescription pads that clinicians can use to give patients notes and recommendations for tobacco cessation. The pads include the phone number of a North Dakota quitline.
Ohio Women's Tobacco Cessation Partnership Team
Funds were used to purchase the patient workbook, "Need Help Putting Out That Cigarette?" and to distribute it to perinatal smoking-cessation projects within four high-risk counties.
Pennsylvania Women's Tobacco Prevention Team
Funds were used for interviews, surveys and focus groups to aid in developing appropriate messaging for smoking cessation kiosks in strategically targeted high-volume ob-gyn clinics.
Southern New Jersey Perinatal Cooperative—Mom's Quit Connection
Funds were used to purchase:
- A permanent display board at the Garden State Discovery Museum. The display advertises the services of Mom's Quit Connection, which provides tobacco-cessation counseling and an interactive activity for young children on the dangers of environmental tobacco smoke.
- A traveling display board to advertise Mom's Quit Connection at professional conferences and community events.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
"Substance Use" in Précis: An Update in Obstetrics and Gynecology. Primary and Preventive Care, Third Edition. Washington: ACOG, 2004. Order book: $59, $49 for ACOG members.
"Smoking and Women's Health" in Special Issues in Women's Health. Washington: ACOG, 2005. Order book: $59, $45 for ACOG members.
ACOG Committee Opinion No. 316. "Smoking Cessation During Pregnancy." Obstetrics & Gynecology, 106(4): 883–888, 2005. (Reprint of report, see below.)
Chapin J and Root W. "Improving Obstetrician-Gynecologist Implementation of Smoking Cessation Guidelines for Pregnant Women: An Interim Report of the American College of Obstetricians and Gynecologists." Nicotine & Tobacco Research, 6(Suppl. 2): S253–S257, 2004. Available online.
Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking. Washington: ACOG, 2002. Order single copy free by emailing firstname.lastname@example.org. Include name, affiliation and mailing address.
Education package includes:
- Case studies
- Patient education booklet and CD
- Slide lecture and lectures notes
- Quick reference card
- "Smoking Cessation During Pregnancy," an ACOG bulletin
Smoking Cessation During Pregnancy. Committee Opinion No. 316. Washington: ACOG, October 2005. Order single copy free by emailing email@example.com. (Replaces Educational Bulletin No. 260, September 2000.)
Audio-Visuals and Computer Software
Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking. PowerPoint presentation. Washington: American College of Obstetricians and Gynecologists, 2002. Available online. Also available as PDF file.
Smoking Cessation for Pregnancy and Beyond: Learn Proven Strategies to Help Your Patients Quit. "Virtual Clinic" CD-ROM. Lebanon, NH: Interactive Medial Library, Dartmouth Medical School, 2004. Download free from Dartmouth or order CD-ROM from ACOG for $25, plus shipping and handling.
"Smoking in Pregnancy: Clinical Perspectives." Washington: ACOG, fielded April 2001 in Ohio. Mailed to more than 1,200 ob-gyns.
"ACOG National Survey on Smoking Cessation During Pregnancy." Washington: ACOG, fielded August–September 2004. Mailed to 5,000 ACOG members nationwide.
"Perinatal Focus Group to Determine Barriers to Using Smoking Cessation Materials," held in conjunction with a June 2004 postgraduate course for ob-gyns in Chicago. Six ob-gyns participated.
World Wide Web Sites
www.acog.org. Web site of the American College of Obstetricians and Gynecologists provides access to information and resources for professionals and patient education materials on smoking cessation. Click "Women's Issues" and then "Smoking Cessation."
Report prepared by: Kelsey Menehan
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans