Smoking & Pregnancy in Underserved Populations: Overcoming Obstacles to Cessation Success

For women who smoke, quitting before or during pregnancy is one of the most powerful ways to improve birth outcomes and protect infants’ health. Not only known to damage the baby’s heart, lungs and brain and increase risk of birth defects, smoking during pregnancy is also closely associated with two leading causes of infant mortality: pre-term birth and sudden infant death syndrome.

Research shows that smoking prevalence is higher among disadvantaged groups and that attempts to quit are less likely to be successful among such groups, which is why the Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN) is working to strengthen smoking cessation efforts in underserved populations. For the IM CoIIN teams in Alaska and Florida, that work involves introducing the Society for Public Health Education’s Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) program to women in rural areas and in low-income households, respectively. An evidence-based method meant to be integrated into routine prenatal care, the SCRIPT program includes components such as counseling and an easy-to-follow booklet called A Pregnant Woman’s Guide to Quit Smoking.

Women in Rural Areas
In remote villages throughout Alaska where the population is predominantly Alaska Native, smoking rates among pregnant women are as high as 50 percent. Since early 2015, the Alaska-based IM CoIIN team has pushed to reduce those rates and promote the SCRIPT program by hosting train-the-trainer workshops in conjunction with Healthy Start in Nome and the North Slope Borough Department of Health and Social Services in Barrow. Both Nome and Barrow are considered regional hubs around which a number of small villages are centered.

“Because regional hubs provide services to nearby villages, and because there are so many villages in each area, we’ve focused on doing the training in hubs with the understanding that providers there would then extend the training to local community health workers,” explains Debbie Golden, director of maternal and child health at March of Dimes.

In late 2015, the Alaska IM CoIIN team began gauging the training’s impact by interviewing workshop participants on their experiences in implementing the SCRIPT program. The team is using insights gained from those interviews to create a supplement to The Pregnant Woman’s Guide to Quit Smoking for women in rural Alaska. In addition to addressing issues distinct to the targeted population (such as the widespread use of smokeless tobacco in remote villages), the handout aims to simplify and streamline the SCRIPT program for healthcare providers and community health workers.

“In small rural communities, many staff members are generalists and often the only care provider in a particular village,” says Golden. “So while rates of tobacco use during pregnancy are high in these places, the small staff numbers make it difficult for a generalist provider to develop the comfort level and expertise of a provider with a specialized role in care for pregnant tobacco users.”

With plans to pilot the supplementary handout with rural providers, the Alaska IM CoIIN team is continuing to carry out post-workshop interviews and adjust its smoking cessation efforts based on its findings.

“The richness of the data we’ve acquired through these interviews is helping us adapt our strategies and, I think, will likely get us closer to an intervention that works for participants than anything else we’ve done so far,” says Golden.

Low-Income Women
In Florida, the state’s IM CoIIN team has joined forces with Florida’s Healthy Start Program to support smoking cessation in women most likely to smoke during pregnancy, including those with low income and low education levels. A statewide initiative signed into law in June, 1991, Florida’s Healthy Start Program works to reduce infant mortality by improving care for women at risk for poor birth outcomes. In April 2016, the Florida-based IM CoIIN team began revising the SCRIPT training program based on feedback from Healthy Start care coordinators. 

“The goal is to increase care coordinator acceptance, knowledge and use of the SCRIPT program to improve the number of underserved pregnant women agreeing to participate in the intervention, as well as to improve the services provided during the intervention,” says Rhonda Brown, RN, BSN, Maternal and Child Health program administrator for the Florida Department of Health.

Scheduled for implementation in a pilot project starting in August, the training program revisions include plain-language explanations of evidence-based data on smoking cessation and expanded information on use of carbon monoxide monitors (a method used to validate smoking status).

Additionally, the Florida team has revised the SCRIPT training program to offer more detailed guidance on moving Healthy Start participants through the stages of change involved in smoking cessation, such as thinking about quitting, preparing to quit, quitting and remaining a non-smoker. This approach emphasizes motivational interviewing, a technique that focuses on encouraging people to explore and surpass uncertainties that may interfere with changing behaviors. Research suggests that motivational interviewing may be especially effective in supporting smoking cessation in low-income pregnant women.

“Focusing on the stages of change is important in promoting smoking cessation with any population,” says Brown. “When a woman becomes pregnant, she’s more receptive to making healthy lifestyle changes. By using motivational interviewing, care coordinators are able to move clients progressively through the stages of change and closer to quitting smoking.”

In a separate pilot project underway at a Healthy Start Coalition, the IM CoIIN team is currently testing the potential benefits of offering diaper vouchers as incentives to SCRIPT program participants. Studies have indicated that incentives may help boost smoking cessation rates among pregnant women, with benefits continuing through the postpartum period.

“One challenge of the SCRIPT model is that is doesn’t include incentives for participants,” says Brown. “Smoking cessation is a behavior change, and behavior changes can be challenging. Standardized incentives given after achieving a program milestone would provide participants with an additional tangible reward for their efforts.”