PREGNANT WOMEN _ SMOKING - PowerPoint

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					       Welcome To
        Counseling
  For Prenatal Smoking
         Cessation
   In the Reproductive
   Health Care Setting




Provided by Development Systems Inc. and the Missouri Department of Health
    Additional Information
   Regarding the Smoking
Cessation Training Program

 The training manual and course was
     supported by Grant/Cooperative
                Agreement
# UT&/CCU713702-05 from the Center
 for Disease Control and Prevention. Its
 contents are solely the responsibility of
   the authors and do not necessarily
     represent the official views of the
     Centers for Disease Control and
                Prevention.
    Training Objectives

 Be able to explain how stopping
  smoking is one of the preventive
  measures likely to have a substantial
  impact on pregnancy outcomes.
 Be able to discuss how this
  pregnancy specific, material, can
  significantly increase rates of
  cessation among pregnant smokers.
 Be able to demonstrate smoking
  cessation counseling.
    Topics To Be Covered In
          The Course
 History of prenatal smoking cessation
  courses and their effectiveness
 Statistics regarding smoking cessation
  and child and reproductive health
 General counseling information
 Theoretical basis for smoking
  cessation - transtheoretical model and
  its application
 Assessing an individual’s dependence
  and need for counseling
 Smoking cessation counseling format
 Useful tools for providers
 Service provider office concerns
 Client resources -- immediate, local
  area, national level
         Introductions

   Pair up with someone you don’t
    know or don’t know well. Get
    the following information about
    them:
    – Name
    – Agency / Position Hold
    – Why are they in the training &
      what do they hope to gain.
    – One thing that they want to share
      about themselves that doesn’t deal
      with work (I.e. Family, Pets,
      Hobbies etc.).
  Why Prenatal
Smoking Cessation
  Counselingis
   Important
Legal Perspective
    Reasons for Conducting
  Prenatal Smoking Cessation
          Counseling

      According to Missouri State
                Law:
 All prenatal care providers must assess
  pregnant women for the risk and current use
  of alcohol, tobacco and other substances.

 All prenatal care providers must provide
  education regarding the effects of smoking
  on pregnant women and their fetus.



              Guidelines
      Refer to ACOG information
Additional Information
    To Take Into
Consideration Before
Beginning Counseling
  Cultural Competence Issues

      Characteristics of Cultural
         Competence Include:
An awareness of one’s own cultural
   values, norms and beliefs
An awareness and acceptance of the
   differences in cultural values, norms
   and beliefs
Broad based knowledge of other
   cultures
The ability to interact successfully in
   different cultural settings and with
   diverse cultural groups
Knowledge of one’s own limitations in
   interacting with individuals from
   other cultural backgrounds.
Historical Information on
 Smoking Cessation and
 Women’s Reproductive
  Health and Pregnancy
        Outcomes
Evidence-based Medicine

It has been estimated that
only 4% of decisions are
based on strong evidence
from clinical research
studies, 45% have no
evidence from research
studies but moderate to
strong consensus among
physicians, and 51% of
decisions are based on little
evidence and consensus.

            Field and Lohr, 1992
  Prenatal Smoking Cessation
     Historical Information
 Incidence of low birth weight decreased
  due to smoking cessation.

 Prenatal smoking cessation interventions
  increase rates of smoking cessation during
  pregnancy.
    Am. Journal of Obstetric Gynecology, Vol. 1, #5, pg. 1328
     – 1334


 Physician/nurse midwives are effective as
  change agents for smoking pregnant
  women.

 15 minute one on one smoking cessation
  sessions accepted better by patients than
  most other methods of non-pharmaceutical
  cessation.
    Health Education Research: Theory and Practice, Vol. 13,
     no. 3, pg. 413-438
 Effects of Tobacco During
         Pregnancy
 Difficulty Conceiving
 Ectopic & Tubal Pregnancies
 Poor Weight Gain
 Chronic Fetal Hypoxia
 Vaginal Bleeding
   Premature rupture of vaginal
    membranes
 Placenta Previa (2X)
 Abruptio Placentae (1.5X)
 Preterm Labor
 Spontaneous Abortion (20%
  Greater in smokers than non-
  smokers)
        Effects on Newborns

   Premature Birth
   Intrauterine Growth Retardation
   Smaller Head Circumference
   Sudden Infant Death Syndrome
    (SIDS)
   Cleft Palate/Lip, Eye and Ear
    Malformations
   Hernias
   Congenital Heart Defects
   Central Nervous System
    Abnormalities
       Poor habituation to sound
       Changes in brain neurochemistry
       Tremors
       Behavior regulation problems
    Effects on Growing Child

   More Respiratory Illnesses
   Diminished Lung Function
   Chronic Otitis Media
   Childhood Cancer
   Impaired Cognitive Abilities
     Diminished reading, verbal and math
      skills
     Lower IQ
     Poorer social skills and behavior
      regulation problems
 Changes in Brain Neurochemistry
  Economic Impact of
 Smoking & Pregnancy
 Overall costs related to
  smoking are between $135 to
  $167 million
   Costs based on placenta previa,
    abruptio placenta, PPROM and pre-
    eclampsia associated with delivery.


 Smoking cessation
  interventions during
  pregnancy shown to decrease
  overall costs of pregnancy and
  care after delivery.
   American Journal of Preventive Med. Volume 15,
    num.. 3, pg. 212-218
    CDC: Smoking Prevalence
    Among Reproductive-aged
           Women

   In 1965, 33% of all U.S. Women
    smoked.

   In 1992, 14.3 million aged 18-44
    years were smokers (26.9%).

   From 1987-1990, prevalence
    declined 3.7%, from 29.6% to 26.9%.

   In Missouri, the overall rate of
    female smoking is 26%; of women
    aged 18-44, 33% are smokers.
CDC: Smoking Prevalence
 and Level of Education

   Prevalence inversely related to
    level of education.

   Highest rates among women
    with less than a high school
    education (40.2% in 1992, but
    down from 46.5% in 1987).
 Smoking Cessation
 During Pregnancy

Stopping smoking is one
       of the few
  preventive measures
    likely to have a
   substantial impact
      on pregnancy
        outcomes.
Smoking Cessation During
      Pregnancy

   Pregnant smokers who stop
    smoking at any time up to the
    30th week of gestation have
    infants with higher birth weight
    than women who smoke
    throughout their pregnancy.


   Pregnant women who stop
    smoking before the 16th week
    have infants with birth weights
    similar to those of babies
    whose mothers never smoked.
Smoking Cessation During
      Pregnancy

    Reductions in
  cigarette smoking
    documented by
      decrease in
   cotinineor other
 biologic markers, or
  by self report, have
 been associated with
  an increase in birth
        weight.
Smoking Cessation During
      Pregnancy

Smoking cessation can also
    result in a permanent
 change in life-style that will
 reduce the risk of smoking-
  related chronic diseases.

This life-style change
    can also be the
  framework on which
   other successful
 behavior changes can
        be based.
Who Needs Cessation
    Counseling
        &
 When Is It Best To
Approach a Pregnant
      Woman



                      23
  Assessing Physical
     Dependence

Smokes within 30 minutes
 after waking?
Has difficulty in places
 where smoking is not
 allowed?
Find first cigarette of day is
 the most satisfying one?
Smokes 3-5 cigarettes a
 day?
Smokes more in morning?
Smokes even when ill?
Inhales?
Opportunities for Counseling :
   Teachable Moments
• 1st trimester              • Points to reinforce
• Opportunities                w/ client
  •   During each               •   It’s never too late to
      prenatal visit                quit
  •   Informing a woman         •   Quitting completely is
      of positive                   best but cutting back
      pregnancy test                is better than
      results                       continued regular
                                    smoking
  •   Discussing ways to
      decrease morning          •   Smoking increases
                                    the risk of miscarriage
      sickness
                                •   Secondhand smoke
  •   Ultrasound
                                    may harm the fetus
  •   First visit w/                too
      partner (if he            •   Having had a healthy
      smokes)                       baby despite smoking
  •   Reviewing medical             in the past does not
      and social history            guarantee the same
      (problems in earlier          this time
      pregnancies may           •   Smoking cessation
      make her feel                 before the 16th week
      vulnerable and                of pregnancy
      more open)                    increases outcomes
                                    of a healthy baby
   Opportunities for Counseling:
      Teachable Moments
                         • Points to reinforce
• 2nd trimester             •   Its never too late to
• Opportunities                 quit
                            •   The development
  • During each                 of the baby is
    prenatal visit              taking place very
                                quickly, so the
  • Hearing the                 mother needs to
                                keep herself
    baby’s heartbeat            healthy. Quitting
    for the first time          smoking reduces
                                the chances of
  • Ultrasound                  having a low birth
                                weight baby
                            •   Smoking decreases
  • When checking               the amount of
    for signs of                blood, oxygen and
    intrauterine                nutrients flowing to
    growth                      the fetus while
                                exercise increases
                                them
  • During                  •   Secondhand
    nutritional                 smoke affects the
    counseling                  fetus
                            •   Quitting completely
                                is best but cutting
                                back is better than
                                continued regular
                                smoking
   Opportunities for Counseling:
      Teachable Moments
• 3rd trimester         • Points to reinforce
• Opportunities            •   It’s never to late to
   • During each               quit; quitting even
     prenatal visit &          right before birth
     when checking             provides more
     for signs of              oxygen and
     intrauterine              nutrients to the
     growth                    baby, and
                               decreases
                               excessive risk of
   • Childbirth                still birth
     classes
                           •   Nutritional needs
   • Hospital visits           are more important
                               due to the rapid
   • Labor and                 growth of the baby
     delivery (in
     smoke-free            •   Children whose
     hospital)                 parents smoke are
                               more likely to
   • Phasing into              develop certain
     post-partum               sicknesses
     counseling
   Opportunities for Counseling :
      Teachable Moments
                           • Points to reinforce
• Post-partum              •   If woman was able to
• Opportunities                quit during pregnancy:
   •   Any telephone            •   Stress the importance
                                    of staying smoke free
       contacts or home             for her baby, other
       visits                       children in the house
                                    and herself
                                •   Work with her to
   •   Post-partum exam             continue her exercise
                                    and diet plan
                                •   Praise her efforts to
   •   Well-baby visits             remain smoke-free
                                    during pregnancy
   •   Family planning     •   If she was able to cut
       appointments            down during
                               pregnancy:
                                •   Get her to enter the
   •   Child                        next stage of quitting
       immunizations                smoking
                                •   Use exercise and diet
                                    to return to
   •   Parenting classes            prepregnancy weight
                           •   If the woman still
                               smokes:
   •   Hospital (post-
                                •   Counsel her not to
       partum unit)                 smoke in areas where
                                    the baby will be
                                    placed
Behavior Change
 Model for Use in
Prenatal Smoking
   Cessation
Frame Work for Smoking
      Cessation:
      Behavioral
Stages of Change Model
  • Precontemplation

  • Contemplation

  • Planning

  • Action

  • Maintenance/Relapse
    Why Stages of Change?

 Behavior change is an ongoing
  process -- rarely does it
  spontaneously occur.
 Persons at different stages of
  need, therefore, use different
  behavior change strategies.
 Not all persons are equally
  ready to change, therefore
  counseling should be tailored
  to the individual.
 Movement from one stage to
  the next may be as important
  as the actual behavior change.
What Is Going on During The
PRECONTEMPLATION Stage

   Client does not have any idea
    that change is needed .

   Education, primarily if the
    person is in precontemplation
    stage.

   Key -- get the person thinking
    about what if… or, I didn’t
    know that could happen….
 Possible Outcomes for
 Women Who Smoke:
 Fertility effects and birth outcomes


 Cardiovascular disease


 Complications with oral contraceptive
  (OC) use

 Cervical cancer


 Early menopause/aggravated
  symptoms

 Osteoporosis


 Slow healing of fractures


 Lung cancer
         Contemplation &
  Planning/preparation: Patient &
       Provider Interactions

 Patient needs support to move to
  planning and action (family, friends,
  provider, etc.)
    Provider provides support to
     attempt cessation.

    Provider helps client recognize
     support structures already in
     place.

    Provider helps patient to develop
     effective cessation strategies.
    READY FOR ACTION
Patient & Provider Interactions

 Client needs support to pick a
  quit date (best when change is
  already taking place, new job,
  home, etc).
 Provider needs to provide
  encouragement to set the
  begin change date.
 Provider needs to emphasize
  that change can take time and
  is a process which needs
  constant reevaluation and
  modification based on
  successes not failures.
 What Factors Motivate
Patient to PLAN and ACT?
     Cost/benefit to person
         What social interaction do they lose?
          What feelings do they lose?
         What do they gain? How much money
          do they save?
     Acute illness (asthma, etc.)
     Media campaigns
         (Reinforcing cessation messages)
     Social pressure
         Not accepted by most people
          currently
     Cessation events
         Classes, courses, national
          campaigns
     Clinician advises to quit
         Most adults look to their primary
          care provider for advice --
          particularly older women
    Withdrawal Symptoms
   Increased anger, aggression, hostility
   Loss of social cooperation
   Emotional imbalance
   Impaired psychomotor and cognitive
    functions
   Cravings
   Depression
   Restlessness
   Anxiety/Tension
   Impatience
   Irritability
   Excessive Hunger
   Fatigue
   Headaches
   Tremors
   Insomnia
Possible Cessation Strategies
To Pick From For Action Stage

 Whatever the method, let client
choose what they believe they can
  do and have success with!!!!!!

    Cold turkey – white knuckle method

                Taper down

    Behavior-focused group cessation

           Nicotine replacement

Acupuncture/hypnosis/alternative strategies
 Smoking Cessation
Pharmacological Methods

 Pharmacological methods are
  primarily used in pre-conceptual
  service and with post-
  partum(non-breast feeding)
  mothers.

 The effects of these therapies
  during pregnancy are unknown
  at this time.

 Nicotine replacement therapy
  (NRT).

 Buproprion/zyban etc.
MAINTENANCE/RELAPSE
Client Provider Interactions
  Often times the maintenance
  stage, although the longest, is
       the least addressed!

 Client needs help to stay smoking
  free.

 Provider needs to emphasize
  relapse prevention skills --
    Trigger recognition and differences
     between successes and relapse
     times.


 Provider needs to give the client
  permission to ask for continued
  support without feeling guilty or
  judged.
MAINTENANCE/RELAPSE
 Resources for Short-term
        Success

     Nicotine replacement

    Telephone hotlines

    Self-help programs

     Provider follow-up
 MAINTENANCE/RELAPSE
Resources for Long-term Success

 Maintenance components of
  cessation programs --
  provider consistency is the
  key.

 Environmental restrictions
  on smoking -- reinforces
  current non-smoking
  behaviors.

 Social norms -- current
  trends in society’s views of
  smoking.
Learning From RELAPSE
  When did it happen?          What
   was different from when you weren’t
   smoking?
  What were you doing?
   What was different from when you
   weren’t smoking?
  Where did the first
   cigarette come from?
   (Friend, family member, did you
   purchase?)
  Did you use a cessation
   aid?
  Will you set another quit
   date? Is there a better time when
   you think you can go longer without
   smoking?
Counseling Help
    Tools
     Basic Counseling
           Tools
 Orient client to the session and build
  rapport.
 Open ended questioning
    Who, what, when, where, how?
       Occasionally can use non-accusatory
        why questions
 Attending skills
    Full attention, verbal and non-verbal given to
     client
 Offer options, not directives
    Provide multiple possibilities regarding
     change
 Give information simply
    Avoid extensive medical terminology
    Avoid jargon
    Does the client want facts or need emotional
     reinforcement
 Summarizing and closure
    Restate any agreements or plans regarding
     stop date
Smoking Cessation During
      Pregnancy
5-15 Minute Counseling Session
    (Also Refer to the 5a’s)
     Determine clients current
      smoking status .
     Review smoking-associated
      risks to fetus, infant and
      mother.
     Review costs/benefits to
      cessation and how to maintain
      current non-smoking
      behaviors.
     Provide self-help manual or
      pamphlet.
     Note smoking status in chart.

     Review status throughout
      pregnancy and support any
      positive changes the patient
      has made.
   Behavior Change Model

Knowledge                   Significance
            Self Efficacy
                               to Self




                               Cost        Benefit




              Provisional
                 Try
Behavior
Change
                                  Capacity
                                  Building
                 Behavior Change Model
Precontemplation




                                                              Contemplation
               Knowledge   Self Efficacy   Significance
                                              to Self
 Maintenance




                                              Cost        Benefit




                             Provisional
               Behavior         Try
               Change
                                                 Capacity
                                                 Building

                             Action                  Preparation
 5 A’s for Providers-- A
    Counseling Tool
   Based on The Stages of Change Model

 ASK/ASSESS about smoking at every opportunity
  -- reinforce non-smoking behaviors
       Determine current level of smoking
       Smoking patterns of family members
       Past attempts to quit smoking
       Current stage in the change model


 ADVISE/EDUCATE all smokers to stop and
  reinforce positive stop smoking messages
     Clear message to quit
     Effects of smoking on mother and child
     Health benefits of quitting


 ASSIST the patient in stopping -- help the patient
  through the contemplation, preparation and action
  stages of changes

 ARRANGE follow-up visits -- for reinforcement of
  behavior changes and modification to plan if
  necessary
          A- ASK/ASSESS
 Assess client’s current level of smoking
    Ask:
        When have thought about quitting in the past
         or since you found out you’re pregnant?
        When was the last time you had a cigarette?
        How many cigarettes did you smoke
         yesterday?
        Why do you think it would be a good idea to
         quit?
        What has kept you from quitting in the past?
        What do you know about how smoking effects
         both you and your baby?

 Assess/ask about smoking patterns in her family

 Assess/ask about any past attempts to quit smoking
  or cut down
    Ask:
         Although you may feel that you failed, you
          were just practicing quitting. You actually
          increase your chances of remaining an ex-
          smoker with each try
         What caused you to start smoking last time?
         What could you do instead of smoking the
          next time this happens?
          A- ASK/ASSESS
                (Continued)

 Identify her current state in the quitting process:
    Precontemplation
    Contemplation
    Preparation
    Action
    Maintenance / relapse

 Record accurate history of smoking cessation
  patterns
              A-ADVISE
 Give the client a clear message to quit
    “ I strongly advise all of our pregnant
     smokers to quit. Your baby will get more
     food and oxygen to grow better and you will
     feel more energetic now and after the baby is
     born.”

 Discuss the health benefits of quitting
    See reference materials for information

 Discuss the effects of smoking on both the
  smoker and children
                A-ASSIST
 If she is in the precontemplation stage: (little or
  no interest in quitting)
     Help her begin to think of reasons why she might
      want to quit smoking sometime in the future
        Ask
             What have you heard about quitting?
             Do you know anyone who has quit?
             What are your concerns or questions about
               quitting?

     If she is willing, brainstorm reasons why she
      should quit for herself and her baby
          Emphasize social, economic, and health
           benefits rather than negative health effects


 If she is in the contemplation, preparation or
  action stage: (thinking about quitting or ready to
  quit in the near future)
     Inform her of the health benefits of not-smoking
     Help her find ways to deal with the barriers that
      keep her from quitting. Help her set a quit date
                      A-ASSIST
                      (Continued)

Respond to specific concerns she may have:

Concern:                                        Response:
 Stress:
                        “Pregnancy can be a stressful time. If you’re
    worried about not having cigarettes to relieve your stress, let’s think
    about other ways you can deal with stress. What else has worked for
    you in the past?”


   Others smoking around the client:
                        “How can you ask your family/friends not to smoke
    near you or to go outside and smoke since their smoke can harm the
    baby? How do you think they would react?”


   Weight gain:
                        “Not all women gain weight when they quit
    smoking. And a little weight gain is normal during pregnancy.”


   Withdrawal symptoms:
                         “Not all smokers have withdrawal symptoms- also
    called signs of recovery. If you have any symptoms, they will lessen
    over time.
                  A-ASSIST
                    (Continued)
 If she is ready to quit:
     Give her current written materials
     Explain: most successful quitters had a plan to
      help them quit. Lets go over these 8 simple steps
      so you can make your own quitting plan
         What are your reasons for quitting?
         When and where do you smoke?
         List three daily habits associated with smoking you
          can change
         Choose three cigarette substitutes you would like to
          use:
                 Deep breathe
                 Drink water
                 Do something else
                 Discuss/talk with a friend or family member
                 Delay smoking
         List how you will treat yourself with the cigarette
          money you’ve saved
         List people you can ask to support your efforts to
          quit smoking (give her the number and first step
          hotline at 1-800-367-2229)
         Make a contract with yourself: starting on quit day,
          you will not beg, bum or borrow anyone else’s
          cigarettes. If you decide to smoke, you will buy and
          smoke your own cigarettes
         Set a quit date
     If she has been able to cut down:
         Say: “It’s great that you were able to cut down. Let’s work
          toward the day you can stop smoking completely. Now, let’s
          set a schedule for next week -- how many cigarettes will you
          smoke a day and when? I think your efforts to cut down have
          been great, congratulations.”
                 A-ASSIST
                    (Continued)
 If she is in the maintenance stage: (has already quit)
 Ask about long term plans regarding smoking
          What are your plans regarding smoking once your
           baby is born?
               Be aware many women take pregnancy pauses in
                smoking!!!!


     Help her refine her list of coping strategies
          Stress
          Support structures
          Smoking friends and/or family

     Talk to her about after the baby is born
          Cigarette temptation
          Weight
          Breast feeding

     If she is feeling angry or sad
          You might say: this feeling is normal. Many smokers
           state that they feel this way after quitting. Smoking
           was an important part of your life and you feel a loss
           when it is gone

     If she wants to try just one
          You might say: “Don’t test yourself. Most people
           who try a cigarette or two go back to smoking.
           You’ve worked so hard to get this far, you can do
           it!!!! REMEMBER NICOTINE IS ADDICTIVE AND IT
           MAY BE HARDER TO STOP ONCE YOU’VE TRIED
           JUST ONE.”
               A-ASSIST
                 (Continued)
 If she is in relapse stage: (had a few
  cigarettes or has gone back to smoking)
    Help her stop the relapse and get back to
     trying to quit.
        What you might say: you’ve just had a slip.
         Don’t worry about the few you’ve smoked,
         you’ve been smoke free for _____ amount of
         time - you can do it again.


    If she has relapsed completely, help her get
     back into the quitting process again move
     her into the action stage quickly. Stress the
     progress she has made and refine her quit
     plan.
        Remind her about multiple attempts before
         quitting - each time she will get farther.
        Get her to explain why she is trying to quit to
         begin with -- health benefits to her and the
         baby.
          A-ARRANGE
 Arrange follow-up
   If she is not ready to quit
       Understanding of quitting being a hard and
        difficult decision.
       Have client think about it and discuss at next
        visit.


   If she has agreed to try to quit smoking
       Make a note -- give additional materials
        provide support phone #’s.
       Explain you will discuss how she is doing at
        next visit.


   If she has already quit smoking
       Make a note to continue dialogue about her
        not smoking at next visit to discover any
        relapse or areas of resistance.
      Behavior Change Model
Precontemplation

  Knowledge




                                                                  Contemplation
                   Self Efficacy               Significance
                                                  to Self


   ASK/ASSESS
                                    ADVISE

                                      ASSIST




 ARRANGE
FOLLOW-UP
                                                  Cost        Benefit




                     Provisional
                        Try
  Behavior
  Change
                                                     Capacity
Maintenance                                          Building

                           Action                   Preparation
Helpful Cessation Checklist for
     Health Care Setting

  Designate a smoking
   cessation coordinator

  Create smoke-free office

  Identify all patients who
   smoke

  Have self-help materials on
   hand

  Develop an intervention and
   follow-up protocol
Office Systems for Tracking
      Client Progress

    Flow charts/smoking
     history (reviewed by
     provider and client -- can
     be used as a
     reinforcement for a
     client’s behavior changes)

    Provider reminder/chart
     sticker

    Client reminder
GOING to A“Smoke FREE”
         Office
   Develop a policy & set the date

   Communicate with staff and
    clients

   Post no smoking signs

   Remove ashtrays

   Display tobacco education
    materials

   Follow-up
Locating Smoking Cessation
   Referral Resources-
      National and Local


 American Lung Association
  freedom from smoking

 American Cancer Association
  fresh start

 Community Hospitals/HMOs

 1-800-4-CANCER
             Counseling Concerns

   Can I really make a difference?
    Yes!     The counselor can provide the smoker with the
    encouragement and support they need to progress through the
    stages of quitting. A helping hand can most definitely make a
    world of difference to someone who is changing life long habits.

   I do not have time to learn how to counsel.
    The information in the packet will give you enough information so
    you feel knowledgeable and comfortable with counseling smokers
    to quit. Assess/Ask, Advise, Assist and Arrange are the 5 A's
    method used to help your client become smoke free.

   Who should do this counseling?
    Counseling is most successful when the team approach is used. The
    more people who participate in the counseling the better the
    outcome will be. Using a combination of person-to-person
    counseling, written materials and follow-up telephone contacts have
    been found to be the most effective approach.

   Can providers who smoke or have never smoked counsel
    effectively?
    If you have not smoked before, be prepared to answer questions
    concerning your expertise on the challenges of quitting smoking.
    Try to share other ex-smokers’ experiences. If you do smoke and
    feel uncomfortable counseling, the client may not feel your are a
    credible source so you probably will not be an effective counselor.
    You should not counsel if you do not feel you can make an impact.
       Counseling Concerns
   Smokers often resist counseling. What can I do?
    Do not push the woman beyond what she is willing to discuss.
    Concerns about previous quitting attempts or making a plan to quit
    should be addressed immediately. Quitting smoking involves
    physical and psychological addiction so you must be there for their
    support.

   What if the smoker has other unhealthy behaviors?
    Give her all appropriate health information and help her set her own
    priorities.

   How do I find time to counsel smokers?
    Counseling sessions as brief as three to ten minutes can be
    effective. Incorporate your smoking cessation counseling when
    doing history, physical exam or routine guidance. Every interaction
    has an impact on the smoker even if there is not time to provide
    materials or have a discussion.

   Where do I begin?
    You already have. Reading this guide is the first step. You must
    first assess the current level of smoking, family-smoking patterns,
    past attempts to quitting and current stage of quitting. Advising and
    educating your client on health consequences of smoking, the
    benefits of quitting, and the effects of smoking on children and the
    mother would then be the next step. You then must assist in the
    stages of change. Arrange a follow-up to evaluate the counseling
    process.
               Identifying Counseling:
      Observations and Techniques
                             Observing Non-verbal Cues
Turning Body Away
Playing with Objects
No Eye Contact
Long Silence Between Responses
Pacing
Rocking
Intense Gestures Towards Counselor
Intense Facial Grimacing

                               Observing Verbal Cues
Quick Denial
Hostile
Inconsistency
Jokes Out of Context
Changes Pace
Blames Others
Angry
Refuses To Answer
Terminates Counseling

                        Effective Non-Verbal Techniques

     Technique                          Effective Use

Physical Proximity                      Arm’s Length
Voice Tone and Speed                    Soft, Soothing, Slow
Posture                                 Lean Forward, Relax
Facial Expression                       Smiling, Interested
Mannerisms/Gestures                     Open, Welcoming
Touching                                Soft and Discreet
Furniture/Physical Setting              No Barriers, Moderate Temp etc.
  SUGGESTIONS: Reaching Pregnant
            Smokers
  Points to Ponder Before Beginning to Counsel

Pregnancy is the ideal time to counsel smokers to
   quit. Women are often motivated to quit to
   protect the health of their unborn babies.
   However, it is important to address the benefits
   of quitting for both the mother and the baby.
   Otherwise, the mother may be able to quit
   during pregnancy but is likely to resume
   smoking after the baby is born.

Some women who smoked during an earlier
  pregnancy may already have a healthy
  baby/child or may have friends who smoked
  during their pregnancies and have healthy
  babies. Since all pregnancies are different,
  emphasize that she increases her chances of
  having a healthy baby this time if she stops
  smoking.

NOTE: Currently, use of the nicotine replacement
  therapy (patch or gum) is not recommended for
  pregnant (or breastfeeding women).
        SUGGESTIONS: Reaching
           Pregnant Smokers
            Counsel From Your HEART as Well as Your Head

1.   Take time to build rapport. Be warm, friendly and caring. Show
     respect for the woman and what she says and feels. Find out what the
     client’s values and needs are. Be concrete and specific in your
     responses.

2.    Be positive and non-judgmental. Some women fear you may criticize
     and lecture them about smoking. Acknowledge that it is not easy to
     quit but encourage her that she will be able to quit smoking and that
     you have confidence in the ability to do this. Suggest she talk to ex-
     smokers about how they quit. If she has tried to quit before, focus on
     the positive aspects of her previous “practice” quit attempts rather than
     on her feelings of failure.

3.   Focus on other positive lifestyle changes she has made (losing weight,
     wearing a seatbelt or healthy eating) to build her confidence. Smokers
     who believe they can quit are the ones who succeed.

4.    Focus on the woman’s feelings and behavior. Every pregnant woman
     has some worries about her pregnancy, her bodily changes, and
     fatigue. Allow her to discuss her concerns and reassure her that such
     feelings are normal.

5.    Remember that stressful situations in a woman’s home or work life
     (like violence, harassment, etc) may contribute to why she smokes or
     why she finds it hard to quit.

6.   Encourage support from others. Ask her to identify family members
     and friends who can help her stop smoking. Together, brainstorm
     ways to ask for help. Discuss whether her partner or close friends
     smoke. If they do, talk about things they can do to help her, like not
     smoking around her or quitting also. If she has no other support, you
     may want to offer yourself as a support person.
    KEY POINTS:Counseling Women Who Smoke

    Counseling is most effective when you join with the
     woman as her partner to develop a personalized
     quitting plan. Having a plan is the critical component
     in successful quitting.

    Assess how ready each woman is to quit and tailor
     your counseling accordingly.

    Problem-solve together to break down each
     woman’s barriers to quitting. Listen well. Help her
     come up with her own answers rather than imposing
     your ideas.

    Quitting is a process that may occur over a number
     of quit attempts. View these attempts as practice
     where she learns what her triggers are and what
     coping strategies work (or don’t work).

    Women are most likely to succeed when they
     believe they can successfully quit or cut down. Your
     confidence in each woman’s ability to quit
     successfully will increase her confidence in herself.
KEY POINTS:Counseling Women
        Who Smoke
   Most women know that smoking is bad for them but
    they need support.

   Women place a high value on a personalized, one-
    on-one approach to receiving new information.
    They prefer receiving advice to stop smoking if it is
    provided in a caring, personal way by someone who
    offers support, avoids blame and guilt, and
    addresses their personal needs.

   It is important to take time to develop rapport and
    put each woman at ease. Use a conversational
    tone of voice, establish eye contact, sit next to her,
    and smile.

   Women with a lower educational level, who lack
    support, or who live with a smoker may have the
    most difficulty quitting.

   Regardless of whether a woman is pregnant, a new
    mother, or thinking about pregnancy, there are
    health benefits for both her and her baby/children
    when she quits smoking.

				
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