Transcript YES

Using 5 A’s and Incentives to
Promote Prenatal Smoking Cessation
PI:
Rebecca J. Donatelle, PhD, CHES
PC:
Deanne Hudson, RN, MPH, CHES
Co-PI: Edward Lichtenstein, PhD
Co-Investigators:
Michael
Wall, MD; Oregon Health Sciences University
Nancy Davis, MPH; Providence Health System CORE
Advisor: Chuck Benz, MD; Providence Health System
Funded by RWJF- Smoke-Free Families: Phase II
Outline of Presentation
Overview
Previous Research:
Oregon WIC Outcomes and Conclusions
Overview MISS Project
MISS Progress to Date
Negative Outcomes From
Prenatal Smoking

Low birthweight (20%)

Preterm Birth (8%)

Perinatal Death (5%)

SIDS

Respiratory Illnesses

Decreased lung function
* CT Orleans et al (2000)
Previous Projects: SOS I, II & III
(Donatelle*, Prows*, Hudson, Champeau)

3-4 Pronged Approaches

Positive incentives (vouchers) to participants alone
or participants and partners for biochemically
confirmed quits

Social support/partners (bolstered and natural)

Community participation

Biomarker feedback
Contingency Management
(Rewards) Theory

Drug abuse is a form of operant behavior that
is maintained in part by the reinforcing effects
of the drug (Higgins 1996, 1997)

Non-drug reinforcer should decrease drug use
(Roll et al 1996, Higgins 1997)

Voucher incentives provided when drug-free
(Silverman et al 1996, Higgins 1997)
Measures/Biochemical Confirmation
(MISS)
Utilize variety of measures/collection methods
Follow Evidence Based Recommendations
Values for quit:
Cotinine (GCMS)  30 ng/ml
 CO Expired air  05 ppm
 Saliva
Summary of SOS-I (RWJF–SFF: I)
Study
Tailored
Woman
Education Choose Incentives Quit
/Advice Partner / Month
%
SOS – I
RCT
Cx 108
Tx 112
Donatelle*, Prows*,
Champeau, Hudson
(2000)
YES
YES
$50./$25.
$50.
9
32
Summary of SOS-II (RWJF)
Study
SOS-II
Pilot
N = 62
Donatelle, Prows, Hudson
Tailored
Education Choose
/ Advice Partner
YES
YES
Woman
Incentives
/ Month
Quit
%
$50.
28
Summary of SOS – III (OHD)
Study
SOS – III
RCT
Cx
60
Tx1 67
Tx2 59
Donatelle, Prows, Hudson
Tailored
Woman
Education Choose Incentives
/ Advice Partner / Month
YES
YES
YES
YES
YES
$25.
$25.
Feedback
Quit
%
YES
12
19
22
SOS I, II & III:
Quit Rates at 8 months Gestation (%)
35
32
28
30
25
22
19
20
15
10
12
9
5
0
I-C
I-Tx
II
III Cx III Tx1 III Tx2
SOS I Cx
SOS I Tx
SOS II
SOS III Cx
SOS III Tx1
SOS III Tx2
Conclusions from SOS I, II & III
 Best Practice-4 A’s are promising in WIC
 ? Would this be effective in private practice/Medicaid
 Incentives (Contingency Management) seem to be
effective
 ? What is the threshold for peak behavioral outcome
 Biomarker feedback
 Partner Support …?
 Utilized various biochemical measures of quit
- may be an important component of the intervention
itself
Maternal Interventions to Stop
Smoking (MISS) Project




Purpose: To significantly increase smoking cessation
behavior among predominantly low-income, high
risk, pregnant women
9 Oregon private practice prenatal clinics
Quit Confirmation (CO and Salivary Cotinine)
RCT: 3 group design



Best Practice 5 A’s
Best Practice 5 A’s plus $25/month voucher
Best Practice 5 A’s plus $75/month voucher
Eligibility Criteria

Pregnant smoker (smoked even a puff in the
last seven days)

15 years of age or older

< 29 weeks gestation at first OB visit

English speaker/reader
MISS Objectives

Determine whether incentives are more
effective than Best Practice in motivating
pregnant smokers to quit

To assess whether a higher incentive will
result in a greater level of smoking cessation
than a lower level incentive
Secondary Project Objectives
Determine:



The integrity/consistency of the intervention as
delivered in private practice managed care clinics
utilizing process measures from both women and
providers.
The importance of selected
psychosocial/environmental factors as predictors of
smoking cessation/reduction in this population.
The cost-per-quit implications for an incentives
model provided in a private practice managed care
clinic.
MISS Methods

Screen all pregnant patients at 1st prenatal visit

Determine eligibility

Obtain informed consent – Randomized by patient

Provider 5A’s

A Pregnant Woman’s Guide to Quit Smoking

Importance of quitting during pregnancy

Local cessation resource guide
MISS Methods Continued

Incentives to Treatment Group Quitters

Follow monthly through 8 months gestation

Postpartum telephone assessments of quitters with salivary
collection from nonsmokers
Best Practice 5 A’s
Ask
Advise
Assess
Assist
A Pregnant Woman’s Guide to Quit Smoking
Local area cessation resource list
Arrange
Summary of MISS Project (RWJF-SFF:II)
MISS-RCT
Cx
Tx 1
Tx 2
Tailored
Education
/Advice
Local
Resource
Pamphlet
Woman
Incentives
/ Month
YES
YES
YES
YES
YES
YES
$25.
$75.
MISS Project To Date
Activity
Screened
Eligible
Enrolled
Participation Rate
Pilot
787
RCT
(8/01-9/02)
2,751
136
430
84
298
Goal: 600
69%
62%
MISS Project Baseline Summary (n=298)
Medicaid/Oregon Health Plan (%)
79
Private Insurance (%)
24
Mean Maternal Age (yrs.)
24.1
Mean Education (yrs.)
11.9
MISS RCT: Light Smokers (<10) and Heavy
Smokers at Baseline by R Group (n=293)
70
62
59
60
60
50
# Women
40
37
35
40
30
Light
Heavy
20
10
0
Control
$25
R Group
$75
Lessons Learned as of Today!



Intervention dependent on fast turn-around for
reinforcement, difficult to find a lab able to comply at
any cost
Although Providers are interested in smoking
cessation during pregnancy and say it is a priority –
they report TIME pressures and demands
Continued clinic monitoring & support/staff
trainings/booster sessions a MUST…
MORE Lessons Learned

Incentives to Clinics

Locate Internal Champion in Clinics

Research Overlay is Staff Intensive

Local Resource List: Providers have Little
Idea of What is Going on in Community

Available for ALL Patients
More…..

Important to be connected in State/Region

Many agencies/programs/other funded projects
promote 5A’s

Cooperation/collaboration important
References

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and
Dependence. Clinical Practice Guideline. Rockville, MD: US
Department of Health and Human Services. Public Health Service. June
2000.

Orleans CT, Barker DC, Kaufman NJ, et al. Helping Pregnant Smokers
Quit: Meeting the Challenge in the Next Decade. Tobacco Control
2000;9(Suppl III):iii6-iii11.

Donatelle RJ*, Prows S*, Champeau D, et al. Randomized Controlled
Trial Using Social Support and Financial Incentives for High Risk
Pregnant Smokers: The Significant-Other Supporter (SOS) Program.
Tobacco Control 2000;9(Suppl III):iii67-69.
References - more

Higgins ST. Some Potential Contributions of Reinforcement and
Consumer-Demand Theory to Reducing Cocaine Use. Addict Behav
1996;21(6):803-816.

Higgins ST. The Influence of Alternative Reinforcers on Cocaine Use and
Abuse: A Brief Review. Pharmacology Biochemistry and Behavior
1997;57(3)419-427.

Silverman K, Wong CJ, et al. Increasing Opiate Abstinence Through
Voucher-Based Reinforcement Therapy. Drug and Alcohol Dependence
1996;41:157-165.

Roll JM, Higgins ST, et al. An Experimental Comparison of Three
Different Schedules of Reinforcement of Drug Abstinence Using Cigarette
Smoking as an Exemplar. Journal of Applied Behavior Analysis
1996;29:495-505.