An analysis of a healthy start smoking cessation program.

Abstract: Despite reports of the adverse effects, many women continue to smoke while pregnant. Consequently, smoking cessation programs are being implemented to deter maternal cigarette use. Repeated studies have been conducted to determine the most effective way to intervene with this population group. Findings show that individual counseling along with tailored self-help materials have been associated with a reduction in cigarette use among pregnant women. This study presents an analysis of such a program that has been implemented by the Healthy Start Coalition of Pinellas, in which 341 women received cessation counseling along with the manual "A Pregnant Woman Self Help Guide to Quit Smoking". The results of this intervention did not detect a significant impact on birth outcomes, however a statistically significant impact was seen on the women's smoking behavior.

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Prenatal smoking has become one of the most studied risk factors in obstetric care (Floyd, Rimer, Giovino, Mullen, & Sullivan, 1993). As the trends in smoking patterns continue to cross the gender lines, more and more women are falling victim to tobacco. Approximately 26% of women of reproductive age use tobacco, smoking on average 14-19 cigarettes per day (Floyd et al., 1993; Adams & Melvin, 1998). Ershoff and colleagues recount that of the numerous women of childbearing age that smoke, only about one third of them quit during pregnancy (Ershoff, Quinn, Boyd, Stern, Gregory, & Wirtschafter, 1999), and Floyd et al. (1993) concludes that about one out of every five pregnant women continues to smoke cigarettes.

BACKGROUND

The adverse effects of smoking while pregnant have been well documented. Increased incidences of intrauterine growth retardation, small for gestational age (SGA), low birthweight (LBW), perinatal mortality, and sudden infant death syndrome have been seen repeatedly in women who smoke throughout their pregnancy (Pollack, Lantz, & Frohna, 2000; Adams & Melvin, 1998; Hakansson, Lendahls, & Petersson, 1999). Public health campaigns have alerted the public about the dangers of smoking and the reduction of risks upon its cessation (Danaher, Shisslak, Thompson, & Ford, 1978), yet 19% of American women report continuing to smoke while pregnant (Adams et al. 1998; Hutchison, Stevens, & Collins, 1996).These numbers may be even higher when nonresponse and deception are considered. Windsor, et al. (2000) report that more than 530,000 pregnant patients annually continue to smoke after entry into prenatal care.

Further indication of the need of smoking cessation is implied in the economic cost to society of maternal smoking. The cost of care for a LBW, premature, or SGA infant far outweighs the costs associated with a normal birth outcome (MMWR, 1997).

Each year in the United States approximately 32,000-61,000 LBW and 14,000-26,000 neonatal intensive care unit (NICU) admissions are attributable to smoking. Smoking is also responsible for 15% of all preterm births (Cohen & Barton, 1998; MMWR, 1997). The average cost to care for one of these infants range from $4,256-$8,640. These figures do not incorporate the extra health care costs of babies who survive but have long-term health care needs due to their initial condition (Cohen & Barton, 1998). When factors such as hospitalizations and physician costs at birth, rehospitalization costs in the first year of life (hospital costs only), and long-term healthcare costs are considered, the cost then ascends to $9,000--$23,000 (Windsor, et al., 1993). As for the mother; the average cost of care for women with the conditions that reveal a positive correlation with smoking is 68%-100% greater than that of normal deliveries, ranging from $7606-$40,069 (Adams et al., 1998).

Although women continue to self-report smoking, Hueston, Mainous, & Farrell (1994) along with Hutchison et al. (1996) are in agreement that pregnancy is a time when women may be particularly receptive to smoking cessation interventions. As investigations into the harmful effects of smoking continue, programs that share a common goal of discouraging tobacco use are constantly being implemented in public health settings. In recent years, special attention has been placed on targeting such programs to pregnant women. Although it is common practice for health care providers to encourage smoking cessation in their pregnant patients, general practitioners rarely use effective smoking cessation techniques and are therefore unlikely to reduce the public health impact of smoking (Humair & Ward, 1998). Studies demonstrated that the application of systematic, multicomponent, prenatal interventions by dedicated providers who used material designed specifically for pregnant women resulted in much higher quit rates than those found in usual care settings (Floyd et al., 1993).

Researchers agree that smoking is harmful to both mother and fetus, however little consensus has been made as to the most effective method of intervention. Multiple studies have been conducted to evaluate the materials used in intervention programs, and to determine the most effective means of assisting women in smoking cessation. In the mid 1980's, Windsor and colleagues conducted a study targeting patients of public prenatal clinics with the purpose of identifying the type of materials that is most effective in helping pregnant women achieve smoking cessation. Participants of the study were divided into three groups. All three groups received the standard clinic information and advice to quit smoking, however groups 2 and 3 were additionally given smoking cessation manuals. Group 2 subjects received a manual published by the American Lung Association that was directed toward promoting smoking cessation amongst the general public, entitled "Freedom From Smoking in 20 Days". Group 3 was given a manual that specifically addressed smoking cessation for pregnant women, "A Pregnant Woman's Self-Help Guided to Quit Smoking". Analysis of the study results indicated that higher cessation rates existed among Group 3 participants than for the other two groups (Windsor, et al., 1988; Floyd et al., 1993). From these findings, it is implied that self-help materials that are specifically tailored towards pregnant smokers better meet the need of women in their attempts to quit smoking.

BACKGROUND ON THE HEALTHY START SMOKING CESSATION PROGRAM

As a community based organization whose goal is to promote comprehensive prenatal and infant health services, the Healthy Start Coalition of Pinellas is dedicated to working to improve the health outcomes of mother and child. In line with these ideals, Healthy Start has instituted an outreach program similar to the one described in the Windsor study in which clients are provided the manual "A Pregnant Woman's Self-Help Guide to Quit Smoking." Additionally, qualified personnel are hired to provide brief counseling sessions with the clients and to encourage the maintenance of a nonsmoking status.

This paper presents an analysis of the intervention put forth by the Healthy Start Coalition of Pinellas. The purpose of the Healthy Start smoking cessation program is to discourage maternal smoking during pregnancy, with the anticipation of promoting a positive birth experience. Results reported in this writing are based on outcome measures of women enrolled in the program from December 1997 to December 1999.

Previous studies suggest that smoking behaviors during pregnancy can be predicted by a woman's sociodemographic characteristics, including age, education, marital status, social status, and partners' smoking status (Connor & McIntyre, 1999; Woodby, Windsor, Snyder, Kohler, & Diclemente, 1999; Hutchison et al., 1996). Factors such as lower socioeconomic status, lower education level, and younger age all influence a woman's likelihood to smoke throughout her pregnancy (Connor & McIntyre; Hakansson et al., 1999). The population served by Healthy Start is primarily composed of single, white women of low socioeconomic status. Many of these women have less than a high school education and are unemployed. Moreover, they mostly live alone with little, if any, social support. Age varies among participants.

DESCRIPTION OF HEALTHY START SERVICES

Clients are referred to the smoking cessation program in one of two ways. When a woman in Pinellas County goes for a routine prenatal visit, she is presented with a Healthy Start screening form that she is asked to complete. If she identifies herself as a current smoker on the form, she is then offered the smoking cessation services. The other method a client is recommended to the program is by way of referral from a case manager. Women receiving other services offered by Healthy Start, who have already established themselves with a case manager, may necessitate smoking intervention and are, thus, also advised of the program. Once the referral has been made, the client is contacted by phone within five days by the smoking cessation health educator, who schedules a home visit to establish face-to-face contact. The home visit is to take place within ten days from the date of the phone conversation.

The home visit is a very critical component of the intervention. At this meeting the health educator is able--build a rapport with the client, place the woman at ease and assess the environment in which she lives. It is believed that the environment in which one lives strongly influences the likelihood of cessation and that it is easier for the pregnant woman to initiate and maintain a smoke-free lifestyle when her surroundings are supportive of that behavior. Furthermore, the more comfortable the woman is during the visit, the more receptive she may be to the intervention.

At this initial visit a plan is established to guide the woman through the process of cessation. She is given the manual "A Pregnant Woman's Self-Help Guide to Quit Smoking" and the health educator thoroughly reviews it with her. The manual is self-paced, and usually takes two weeks to complete.

After the face-to-face meeting, the woman is followed up until her delivery; and the birth outcome is recorded. The time spent with each client varies from case-to-case, as some women require more intervention than others.

STATISTICAL ANALYSIS

A total of 1144 women were initially contacted about the smoking cessation program, with 341 (29.8%) of them remaining in the program until giving birth. Of the women contacted, 626 (54.6%) did not receive smoking cessation services, 177 (15.4%) began but did not complete the program. The reasons for exiting the program or nonparticipation were identified to be as follows: having given birth explained 34.8% of the exits, while 3.7% of the women had a miscarriage or stillbirth. Approximately 16.1% of the women were unable to be located or contacted after initial contact, with 3.1% having moved. Additionally, 18.3% of the women reported no longer smoking, 12.7% declined services, and 6.9% were nonresponsive to the initiatives made by the health educator. Lastly, 3.9% were found to be ineligible due to unspecified reasons.

One-way analysis of variance (ANOVA) was used for statistical analysis to make comparisons between each group of subjects, i.e. those that did not receive services, those that did not complete the program, and those that did complete the program. Outcome measures include birthweight, SGA births, prematurity, and the number of cigarettes reported at exit. Other variables analyzed were number of cigarettes reported at entry and the number or service units the clients received from the health educator, where one service unit is equal to 15 minutes of time spent together. To ascertain demographic comparisons, mother's age and education level were also included in the analysis.

RESULTS

The ANOVA revealed a statistically significant difference in mother's age (M=24.2, 25.9, 24.9; F= 3.87; p = .021), where M equals the mean score for the group that did not receive smoking cessation, the group that began but did not complete the program, and the women who remained in the program throughout their pregnancy, respectively. A statistically significant difference was noted in the number of service units received from the smoking cessation health educator (M= .04, 15.1, 19.7; F= 86.51, p< .001). Significance was further noted in the change in the number of cigarettes smoked (M= .04, 1.9, 8.2; F= 131.41; p< .001). Statistically significant associations were also reported with the number of cigarettes reported at entry into the program (M= 2.4, 13.1, 12.43; F= 383.26, p< .00I) and the number of cigarettes reported at exit (M= .99, 13.0, 4.3; F=98.23, p< .001). As for birth outcomes, this analysis failed to reveal a significant difference for prematurity (M= 0.28, 0.33, 0.23; F= 1.48, p= .228) and the birthweight of the baby (M= 3194.2, 3032.4, 3161.6; F= 2.87, p= .05). There was, however, a significant difference with SGA (M= -8.7,-8.3,-8.8; F= 4.13, p= .016). These findings are summarized in Table 1.

DISCUSSION

With the exception of SGA, the results of the birth outcome measures presented in this data failed to support the findings of other researchers, who suggest that smoking cessation reduces the rate of low birth weight and premature births. One possible reason for this is the effects of the small sample size. With 803 of the women who were initially contacted being excluded from the analysis, it is possible that the sample of only 341 women limited the power of the statistical test, thus hindering it's ability to detect any potential differences in the birth outcomes between the groups of women. Of the subjects included in the analysis, women who did not receive smoking cessation services or who began but did not complete the smoking cessation program had similar birth outcomes to those women who did complete the program. Hence, the comparisons made between the three groups of women failed to suggest a strong association between the impact of the smoking cessation program on low birthweight and premature births.

Whereas this data did not provide support for improved birth outcomes, benefits of the intervention was demonstrated with the significance reported in the reduction in the number of cigarettes smoked. When measuring success by this variable, those women who received the most service units from the Healthy Start smoking cessation health educator had greater outcomes. This finding contributes to the report made by Floyd et al. (1993) that the most successful prenatal smoking cessation programs are the ones that employ a multifaceted curriculum in which designated providers deliver one-on-one individualized counseling for the clients throughout their pregnancy.

The numbers of cigarettes reported in this data was based on self-report. According to Floyd et al. (1993), self-report is the most direct, practical, and widely used method of reporting smoking behavior. Several validation studies indicate that self-reporting gives a good picture of smoking status (Parazzini et al., 1996; Hakansson et al., 1999), however the decision to rely on self-report should be based on the type of program and population being studied (Floyd et al., 1993).

CONCLUSION

As research progresses in the field of prenatal smoking cessation, demonstration of an improvement in birth outcomes as a consequence of a systematic cessation program has become an important study objective (Floyd et al., 1993). Smoking during pregnancy is a behavior that needs to be addressed to help ensure the health and survival of newborns. The argument for adoption of cessation programs that involve brief counseling along with self-help material tailored for the pregnant woman is supported by researchers who have found significant evidence of their effectiveness. The application of various intervention methods has been shown to be more effective than routine advice given during prenatal care visits and brief, individual counseling has been shown to have long-term effects (Hakansson et al., 1999). The Robert Wood Johnson Foundation found that brief counseling of 5-10 minutes was effective and that more intensive counseling had not been found reliably to improve effectiveness. Furthermore, brief counseling of 5 to 10 minutes increases validated cessation by 70% in pregnant smokers (Mullen, 1999). The average time spent with the women who completed the Healthy Start smoking cessation program was approximately five hours over a mean period of 159 days (from enrollment to delivery). Consistent with the other findings, these brief counseling sessions coupled with the use of the self-help manual proved to be adequate in altering the smoking behavior of the women enrolled.

The effects of intervention have been reported and confirmed by multiple studies. One effect of intervention may be to move up cessation earlier than it would have occurred in the absence of intervention. Other positive effects include continued abstinence after the birth and significant reduction in the amount of cigarettes smoked by women who are unable to stop completely (Mullen, 1999). Although the data used in this study did not contain information regarding the smoking status of the mother beyond delivery, the women were noted to report fewer cigarettes at the exit of the study, in addition to the greatest change in the number of cigarettes smoked when compared to women who did not complete the program. Moreover, we can postulate that cessation was implemented earlier than it would have been, had the intervention not taken place.

This report contributes to the existing literature on smoking cessation in several ways. First, our findings on the impact of intervention on the smoking behavior of expectant mothers supports the claims made by other researchers in the area. Secondly, by reporting the associated costs of negative birth outcomes attributable to maternal smoking, we have taken the prospective beyond that of mother and child, and have linked it to the implications on the health care system. Lastly, we have shown that the rewards of smoking cessation are multifaceted. These rewards come not only in achieving a positive birth experience, but also in promoting a healthy behavioral change among pregnant smokers.

Table 1. Comparison of outcome and demographic measures of those who
did not receive the intervention, those who received some of the
intervention, and those who completed the intervention program.

                           No  SC *

     Measure          N      MS      D

Cigarettes smoked
  at entry           207     2.4    6.12
Cigarettes smoked
  at exit            141     1.0    3.86
Change in
  cigarettes
  smoked             140     0.0    0.42
Small for
  gestational age    399    -8.8    1.56
Mother's age         399    24.2    5.99

                           Some SC

     Measure          N      M       SD

Cigarettes smoked
  at entry           167    13.1    8.50
Cigarettes smoked
  at exit             64    13.0    8.97
Change in
  cigarettes
  smoked              64     1.9    5.50
Small for
  gestational age    117    -8.4    2.53
Mother's age         117    25.9    5.78

                         Complete SC

     Measure          N      M       SD       F         P

Cigarettes smoked
  at entry           339    12.4    8.13    383.25    <.001
Cigarettes smoked
  at exit            328     4.3    5.22     98.23    <.001
Change in
  cigarettes
  smoked             328     8.2    6.63    131.41    <.001
Small for
  gestational age    290    -8.8    1.30      4.13     .016
Mother's age         290    24.9    6.10      3.87     .021

* SC= smoking cessation

Acknowledgment: The authors of this manuscript would like to thank Pinellas Healthy Start for supplying the data and support.

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Dionne Mayhew, MPH, CHES is in the Department of Family Medicine at the University of South Florida. Karen M. Perrin, PhD, MPH, RN is an Assistant Professor in the Department of Community and Family Health at the University of South Florida. Wendy Struchen, MPH, MEd is a Maternal and Child Health Epidemiologist with the St. Petersburg Healthy Start Federal Project. Address all correspondence to Karen M. Perrin, PhD, MPH, RN, University of South Florida College of Public Health, Department of Community and Family Health, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL 33612; PHONE: [phone] ext. 2208; FAX [phone]; E-MAIL: [e-mail].