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Preventive Medicine 81 (2015) 438?443
Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed
Impact of the 5As brief counseling on smoking cessation among pregnant
clients of Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) clinics in Ohio?
Oluwatosin Olaiya a,b,?, Andrea J. Sharma a,c, Van T. Tong a, Deborah Dee a,c, Celia Quinn b,d, Israel T. Agaku b,e,
Elizabeth J. Conrey a,d, Nicole M. Kuiper e, Glen A. Satten a
a
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
Epidemic Intelligence Service, Division of Applied Sciences, Scienti?c Education and Professional Development Program Of?ce, Centers for Disease Control and Prevention, Atlanta, GA, USA
c
U.S. Public Health Service Commissioned Corps, Atlanta, GA, USA
d
Ohio Department of Health, Columbus, OH, USA
e
Of?ce on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
b
a r t i c l e
i n f o
a b s t r a c t
Objectives. We assessed whether smoking cessation improved among pregnant smokers who attended
Women, Infants and Children (WIC) Supplemental Nutrition Program clinics trained to implement a brief
smoking cessation counseling intervention, the 5As: ask, advise, assess, assist, arrange.
Methods. In Ohio, staff in 38 WIC clinics were trained to deliver the 5As from 2006 through 2010. Using
2005?2011 Pregnancy Nutrition Surveillance System data, we performed conditional logistic regression,
strati?ed on clinic, to estimate the relationship between women’s exposure to the 5As and the odds of selfreported quitting during pregnancy. Reporting bias for quitting was assessed by examining whether differences
in infants’ birth weight by quit status differed by clinic training status.
Results. Of 71,526 pregnant smokers at WIC enrollment, 23% quit. Odds of quitting were higher among
women who attended a clinic after versus before clinic staff was trained (adjusted odds ratio, 1.16; 95%
con?dence interval, 1.04?1.29). The adjusted mean infant birth weight was, on average, 96 g higher among
women who reported quitting (P b 0.0001), regardless of clinic training status.
Conclusions. Training all Ohio WIC clinics to deliver the 5As may promote quitting among pregnant smokers,
and thus is an important strategy to improve maternal and child health outcomes.
Published by Elsevier Inc.
Available online 31 October 2015
Keywords:
Smoking cessation
Pregnancy
Counseling
WIC
Ohio
Introduction
The adverse effects of perinatal smoking are well documented and
include placental abruption, preterm birth, low birth weight, and infant
death (Anon., 2004; Alberg et al., 2014). Smoking prevention and cessation can prevent pregnancy-related adverse outcomes. Despite overall
declines in perinatal smoking rates in the U.S. during 2000?2010
(Tong et al., 2013), perinatal smoking rates remain disproportionately
higher among low-income women (Tong et al., 2013). Furthermore,
almost half of the women who smoke prior to becoming pregnant will
quit smoking before their ?rst prenatal visit (Tong et al., 2008); thus,
? The ?ndings and conclusions in this report are those of the authors and do not
necessarily represent the of?cial position of the Centers for Disease Control and
Prevention.
? Corresponding author at: Division of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and Prevention
(CDC), 4770 Buford Highway, MS F-74, Atlanta, GA 30341, USA.
E-mail address: oolaiya@cdc.gov (O. Olaiya).
women who continue to smoke during prenatal care may be those
who need extra help to stop smoking (Chamberlain et al., 2013).
Smoking cessation counseling is an effective public health intervention to help pregnant smokers quit (Chamberlain et al., 2013; Lumley
et al., 2009; Anon., 2010). The U.S. Public Health Service (USPHS)
recommends a ?ve-step, evidence-based approach known as the 5As,
whereby trained providers deliver brief counseling to help their clients
quit smoking (Fiore et al., 2008). The steps include:
(1) ASK every client whether they smoke; it is recommended that
providers identify and document each client’s tobacco use status
at every visit.
(2) ADVISE smokers to quit; providers should give advice to quit to
each client in a clear, strong and personalized manner.
(3) ASSESS smokers’ willingness to quit; at each visit.
(4) ASSIST smokers using evidence-based aids; if the client is willing
to quit, the provider should offer or refer for counseling and/or
provide medication unless otherwise contraindicated. If
the client is not willing to consider quitting at the moment,
http://dx.doi.org/10.1016/j.ypmed.2015.10.011
0091-7435/Published by Elsevier Inc.
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O. Olaiya et al. / Preventive Medicine 81 (2015) 438?443
providers should provide a brief intervention that promotes
motivation to quit.
(5) ARRANGE for follow-up; either by telephone or in person soon
after the set quit date.
Systems and implementation strategies, such as documentation of
the 5As steps at every clinic visit, are recommended by the USPHS to
ensure that all smokers are identi?ed and provided counseling and
referral to smoking cessation resources (Fiore et al., 2008).
The Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) serves low-income pregnant and postpartum
women and young children. WIC provides nutrition and breastfeeding
education and counseling, food vouchers, and referrals to health care
and other community resources. Whereas WIC programs do not provide
direct prenatal care services, they do reach a large proportion of
low-income women during the perinatal period; thus, WIC can serve
as a venue for delivering the 5As to increase perinatal smoking cessation
and improve maternal and infant health outcomes. In 2013, a Cochrane
Review evaluated the effectiveness of smoking cessation counseling
approaches, such as the 5As, and found modest improvements in
perinatal smoking cessation (average risk ratio, 1.44; 95% con?dence
interval, 1.19?1.75) (Chamberlain et al., 2013). Results were consistent
for women of all socioeconomic categories (Chamberlain et al., 2013).
Ohio’s infant mortality rate (7.9 deaths per 1,000 live births) is one of
the highest in the U.S., and exceeds the overall U.S. rate (6.1 deaths per
1,000 live births) (Deaths: Final Data for 2011). According to the
Pregnancy Risk Assessment Monitoring System (PRAMS), over the
past decade, nearly 20% of pregnant women in Ohio smoke during
their third trimester (CDC’s PRAMS On-line Data for Epidemiologic
Research). Recognizing the need to improve perinatal smoking
cessation, starting in 2006, the Ohio Department of Health (ODH)
trained select WIC clinics to deliver the 5As to their clients and integrate
delivery of the 5As into their clinic ?ow. The purpose of this study was to
assess whether training the WIC clinics to implement the 5As improved
smoking cessation.
Methods
Data sources
The primary data source was 2005?2011 data from the Centers for Disease
Control and Prevention’s (CDC) Pregnancy Nutrition Surveillance System
(PNSS), a program-based surveillance system created to monitor the prevalence
of nutritional and behavioral risk factors related to mortality and low birth
weight among infants of low-income pregnant women (Pediatric and
Pregnancy Nutrition Surveillance System). Data are collected on pregnant
women receiving services at WIC clinics. Participating states aggregate all
clinic-level data and then submit them to PNSS. The PNSS data include sociodemographic characteristics; self-reported behaviors before, during, and after
pregnancy; and indicators of maternal and infant health.
At the time of the initial WIC visit, women report their current smoking
behaviors, as well as their smoking behaviors during the 3 months prior to the
pregnancy. Similarly, at the postpartum WIC visit, women report their current
smoking behaviors as well as their smoking behaviors during the last 3 months
of pregnancy. Therefore, the surveillance system allows for assessment of
changes in smoking behavior (e.g., quitting) over time based on changes in
documented self-reported smoking status. This study was determined to be
exempt from review by the CDC’s institutional review board.
Inclusion criteria and outcome variable
From 2005 to 2011, all women who enrolled in any Ohio WIC clinic during
their ?rst or second trimester and reported they were currently smoking at
the time of WIC enrollment were eligible for analysis (n = 81,313). Our
outcome variable was quitting smoking. Women who reported smoking no
cigarettes during the last 3 months of pregnancy were categorized as having
quit.
439
Exposure to 5As intervention
Data obtained from ODH on the year(s) of implementation of the 5As
within clinics was used to determine a woman’s exposure to the intervention. In 2006, ODH began a pilot project to train personnel at WIC clinics
to implement the 5As. The training continued in phases and by 2011,
personnel at 38 of approximately 200 WIC clinics had been trained. The
pilot counties were selected by ODH because of their high rates of tobacco
use, infant mortality, and racial disparities in birth outcomes. A more
detailed description of the pilot training is described elsewhere (Ohio
Partners for Smoke-Free Families Final Report, 2007). All women attending
a clinic that had been trained by ODH to deliver the 5As, beginning with the
same calendar year in which the clinic was trained, were categorized as
exposed to a trained clinic. Women attending a clinic in any year prior to
training (including women who attended a clinic that was never trained)
were categorized as not exposed to a trained clinic.
We further characterized a woman’s 5As exposure according to clinic documentation practices. As part of the 5As implementation, ODH required that documentation of the 5As steps be made on a Five As Intervention Record (FAIR)
form, which was maintained in a woman’s chart. ODH staff provided technical
assistance to help clinics integrate the steps of the 5As into clinic procedures
and conducted periodic chart reviews among clinics who reported using the
form. Trained clinics that included FAIR forms in any charts were categorized
as ?trained, documenting? while trained clinics that reported not currently
using the FAIR form were categorized as ?trained, not documenting?. We categorized trained clinics by this documentation status because documentation
was the only way we could objectively assess whether a trained clinic was
implementing the 5As intervention. Clinics that were trained but were not
documenting may or may not have been implementing the 5As. The periodic
chart reviews allowed a clinic’s documentation status to change over time. A
typical example of how a clinic could be categorized over time is illustrated in
Fig. 1. The clinic categories (i.e., untrained, trained/documenting 5As, trained/
not documenting 5As) were used as proxies for a woman’s exposure to the
5As intervention, as individual-level exposure to the 5As could not be determined in PNSS.
Covariates
Socio-demographic characteristics assessed included maternal age, in years
(b15, 15?17, 18?19, 20?29, 30?39, or =40); race/ethnicity (non-Hispanic white,
non-Hispanic black, Hispanic, American Indian/Alaska Native, Hawaiian/Paci?c
Islander/Asian, or multiple race); education (b 12, 12, or N12 years of schooling); and county type (metropolitan, suburban, Appalachian (Appalachian
Regional Commission), rural non-Appalachian). Women were categorized as
heavy smokers if they reported smoking 10 or more cigarettes per day at the
initial prenatal WIC visit.
Exclusion criteria
Of the 81,313 women eligible for the study, we excluded 12.0% for whom
quitting status in the last 3 months of pregnancy could not be ascertained
because they did not return for a postpartum visit. One woman was further
excluded due to missing covariate data. The ?nal analytic sample included
71,526 women. Women missing postpartum smoking data were included in a
sensitivity analysis.
Statistical analysis
We used ?2 statistics to compare the characteristics of women included in
our analysis to those excluded due to missing data. We used (conditional
logistic) regression to assess the association between exposure to the 5As and
quitting. Because the characteristics of the trained and untrained clinics and
their respective clients differed, and because some of these characteristics are
unmeasured, we strati?ed by clinic to compare the odds of quitting smoking
among women who attended a clinic before the clinic was trained in the 5As
(reference period) to the odds of quitting smoking among women who
attended the same clinic after the clinic was trained. We used conditional logistic regression to avoid estimating a separate intercept for each clinic. To further
examine associations related to clinic documentation of the 5As, we compared
the odds of quitting among women who attended a clinic before it was trained
in the 5As (reference period) to women who attended during the ?trained and
documenting period? and to women who attended during the ?trained but not
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440
O. Olaiya et al. / Preventive Medicine 81 (2015) 438?443
Fig. 1. Schema representing how a woman’s exposure to the 5As was determined using a hypothetical Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
clinic (clinic X). In this example, clinic X?s staff received 5As training in 2008. Ohio Department of Health chart reviews indicated that the clinic documented the implementation of the 5As
using the Five As Intervention Record (FAIR) form through 2010, but did not document with the FAIR form in 2011. Hence, women who attended clinic X from 2005-2007 were considered
not exposed to the 5As, women who attended from 2008-2010 were considered exposed to the 5As and the clinic was documenting the 5As steps, those who visited in 2011 were considered exposed to the 5As but the clinic was not documenting the 5As steps. In the analysis, all clinics include 2005 ? 2011 data, but the actual year each clinic was trained to deliver the
5As varies. After training, some trained clinics continuously documented the 5As steps, others ceased documentation and some never adopted documentation into clinic records.
documenting period? (as shown in Fig. 1). We controlled for maternal age,
race/ethnicity, education, trimester of WIC enrollment, heavy smoking at
?rst prenatal visit, and calendar year. We included the calendar year that
the mother attended the clinic in our model to account for secular trends
in smoking and quit rates. Women attending clinics that were never trained
were included in the analysis to provide additional information on secular
trends as well as the effect of potentially confounding covariates. Because
heavy smokers may be less likely to quit (Freund et al., 1992) and demographics and smoking norms differ substantially among Ohio regions, we
tested if the effect of clinic training was different among heavy smokers or
different by county type by including multiplicative interaction terms between training status and heavy smoking and training status and county
type in the model. To assess the impact of loss to follow-up, we conducted
a sensitivity analysis where all women excluded due to missing data on
smoking status during the last 3 months of pregnancy were assumed to
have continued smoking. Smoking cessation is known to increase birth
weight (Chamberlain et al., 2013), thus as a secondary analysis, we assessed
the difference in mean birth weight, adjusted for covariates, between
quitters and smokers. Additionally, because disclosure of smoking may
differ among women receiving a smoking cessation intervention (Windsor
et al., 1993), as a proxy assessment of reporting bias, we assessed whether
the difference in mean birth weight between quitters and smokers differed
by clinic training and documentation status. Analyses were performed using
SAS 9.3 (SAS Institute Inc., Cary, North Carolina). We de?ned statistical
signi?cance at P b 0.05 for main effects and P b 0.15 for interactions.
Results
Among the study sample, about half (52.8%) enrolled in WIC during
the ?rst trimester of pregnancy compared to the second trimester, 42.7%
were heavy smokers at their initial WIC visit, and 5.4% and 6.5% of
women attended trained/documenting and trained/not documenting
clinics, respectively. Overall, 23.0% of women quit smoking by the last
3 months of pregnancy. In comparisons of the characteristics of
women who were included versus excluded from analysis, a greater
proportion of excluded women had b 12 years of education, enrolled
in WIC in the ?rst trimester, and were of a racial/ethnic group other
than non-Hispanic white (Table 1)
The odds of quitting smoking were signi?cantly higher among
women who visited a clinic after it had received 5As training
compared with women who visited the same clinic prior to training
(adjusted odds ratio [aOR], 1.16; 95% con?dence interval [CI], 1.04?
1.29) (Table 2). Associations were similar for women who attended
a clinic when it was documenting the 5As (aOR, 1.18; 95% CI, 1.03?
1.35) or when it was not documenting the 5As (aOR, 1.14; 95% CI,
0.98?1.32) compared with women who attended prior to training.
However, the latter association was not statistically signi?cant (p =
0.08) (Table 2).
Table 1
Characteristics of pregnant smokers attending Ohio WIC clinics who were included and
excluded from the analysis due to missing data (Pregnancy Nutrition Surveillance System,
2005?2011).
Included
Characteristics
N
Maternal age (years)
b15
15?17
18?19
20?29
30?39
40+
Maternal race/ethnicity
Non-Hispanic white
Non-Hispanic black
Hispanic
American Indian/Alaska Native
Hawaiian/Paci?c Islander/Asian
Multiple races
Maternal education (years completed)
b12
12
13?30
Missing
Trimester enrolled in WIC
1st
2nd
County type
Metropolitan
Suburban
Rural, non-Appalachian
Appalachian
Smoking intensity at WIC enrollment
Light (b10 cigarettes/day)
Heavy (=10 cigarettes/day)
Quit smoking in last 3 months of
pregnancy
No
Yes
Type of clinic attended
Untrained in the 5As
Documenting the 5As
Not documenting the 5As
71,526
154
3,666
11,643
45,646
9,800
617
71,526
60,857
8,128
1,340
253
252
696
71,526
24,544
38,492
8,490
71,526
37,756
33,770
71,526
30,259
8,646
11,852
20,769
71,526
40,977
30,549
71,526
55,043
16,483
71,526
63,005
3,849
4,672
Excluded?
(%)
(0.2)
(5.1)
(16.3)
(63.8)
(13.7)
(0.9)
(85.1)
(11.4)
(1.9)
(0.4)
(0.4)
(1.0)
(34.3)
(53.8)
(11.9)
(52.8)
(47.2)
(42.3)
(12.1)
(16.6)
(29.0)
(57.3)
(42.7)
(77.0)
(23.0)
9,787
11
488
1,568
6,105
1,474
141
9,753
7,814
1,556
215
38
40
90
9,787
3,907
4,771
1,107
2
9,787
5,814
3,973
9,787
4,893
1,097
1,371
2,426
9,787
5,477
4,310
466
367
99
9,787
(88.1) 8,758
(5.4)
504
(6.5)
525
? Excluded due to missing data required for analysis.
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N
(%)
P-value
b0.001
(0.1)
(5.0)
(16.0)
(62.4)
(15.1)
(1.4)
b0.001
(80.1)
(16.0)
(2.2)
(0.4)
(0.4)
(0.9)
b0.001
(39.9)
(48.8)
(11.3)
(0.0)
b0.001
(59.4)
(40.6)
b0.001
(50.0)
(11.2)
(14.0)
(24.8)
0.04
(56.0)
(44.0)
0.36
(78.8)
(21.2)
b0.001
(89.5)
(5.2)
(5.4)
O. Olaiya et al. / Preventive Medicine 81 (2015) 438?443
441
Table 2
Conditional logistic regression analysis estimating odds of smoking cessation in the last 3 months of pregnancy among pregnant smokers attending a WIC clinic before or after the clinic
was trained to deliver the 5As, overall and by documentation status (Ohio, 2005?2011).
By Training Status
5As exposure status??
Crude OR (95% CI)
By Training and Documentation Status
Adjusted OR (95% CI)?
Crude OR (95% CI)
Adjusted OR (95% CI)?
Clinic untrained
1.00
1.00
1.00
1.00
Clinic trained
1.19 (1.09?1.32)
1.16 (1.04?1.29)
?
?
Documenting 5As
?
?
1.20 (1.06?1.37)
1.18 (1.03?1.35)
Not documenting 5As
?
?
1.18 (1.03?1.36)
1.14 (0.98?1.32)
?
?
?
?
?
?
2.36 (1.68?3.32)
1.52 (1.40?1.64)
1.30 (1.24?1.36)
1.00
0.81 (0.77?0.86)
0.79 (0.64?0.98)
?
?
?
?
?
?
2.36 (1.68?3.32)
1.52 (1.40?1.64)
1.30 (1.24?1.36)
1.00
0.81 (0.77?0.86)
0.79 (0.64?0.98)
?
?
?
?
?
?
?
1.00
1.75 (1.64?1.86)
1.74 (1.54?1.96)
1.18 (0.88?1.60)
0.77 (0.56?1.07)
1.04 (0.87?1.24)
1.08 (1.06?1.09)
?
?
?
?
?
?
?
1.00
1.75 (1.64?1.86)
1.74 (1.54?1.96)
1.18 (0.88?1.60)
0.77 (0.56?1.07)
1.04 (0.87?1.24)
1.08 (1.06?1.09)
?
?
1.31 (1.27?1.36)
1.00
?
?
1.31 (1.27?1.36)
1.00
?
?
?
2.71 (2.60?2.82)
1.00
1.01 (1.00?1.02)
?
?
?
2.71 (2.60?2.82)
1.00
1.01 (1.00?1.02)
Covariates
Maternal age (years)
=15
15?17
18?19
20?29
30?39
40+
Maternal race/ethnicity
Non-Hispanic white
Non-Hispanic Black
Hispanic
American Indian/Alaska Native
Hawaiian/Paci?c Islander/Asian
Multiple races
Maternal education (years)
Trimester enrolled in WIC
1st
2nd
Smoking intensity at WIC enrollment
Light (b10 cigarettes/day)
Heavy (=10 cigarettes/day)
Calendar year
OR, odds ratio; CI, con?dence interval.
?
Covariates include trimester enrolled in WIC; heavy smoking (=10 cigarettes/day); year of clinic attendance; maternal age, race, education.
?? Women’s exposure status is based on whether or not the clinic had been trained to deliver the 5As and whether or not the clinic was documenting its delivery of the 5As.
The association between attending a trained clinic and quitting
smoking did not differ between heavy or light smokers (p-value for interaction, p = 0.64), but may differ by county type (p-value for interaction, p = 0.10). In rural, non-Appalachian counties and Appalachian
counties, the odds of quitting smoking were higher among women attending a clinic after it was trained compared with women who visited
the same clinic prior to training aOR (1.31; 95% CI, 1.07?1.60) and aOR
(1.25; 95% CI, 1.01?1.54), respectively. There was no difference in the
odds of quitting smoking by clinic training status among women
attending clinics in metropolitan (aOR, 1.00; 95% CI, 0.83?1.20) or
suburban (aOR, 0.96; 95% CI, 073?1.27) counties. Associations were
nearly identical with the sensitivity analysis, where women with
missing postpartum smoking information (n = 9,787) were considered
not to have quit (Supplemental Table 1).
For the secondary analysis, 66,811 women (93.4% of the study sample) had data on infant birth weight. Women missing birth weight data
tended to be older, non-white, less educated, enrolled in WIC during the
?rst trimester, and to have attended a non-trained clinic, but there was
no difference in the proportion who reported quitting smoking (data
not shown). The adjusted mean birth weight was an average of 96 g
higher among women who reported quitting smoking; there was no
signi?cant effect modi?cation by clinic training or documentation status
(test for interaction, P = 0.40) (Table 3).
Discussion
The odds of reported smoking cessation by the last 3 months of pregnancy among pregnant women attending Ohio WIC clinics were higher
after the clinics received 5As training. Our study adds to the body of evidence supporting the effectiveness of a brief smoking cessation
counseling intervention, particularly the 5As, for pregnant women.
The intervention was delivered as part of routine WIC program services
by trained WIC personnel, most of whom were not physicians, thus further supporting evidence that the 5As delivered in a non-clinical context
can be effective in increasing smoking quit rates (Fiore et al., 2008).
Table 3
Mean birth weight (grams) among smokers and quitters by clinic training and documentation status (Ohio, 2005?2011).
Smoked Throughout Pregnancy
Overall??
Women’s 5As exposure status?
Untrained
Trained, documenting the 5As
Trained, not documenting the 5As
Quit By Last 3 Months of Pregnancy
n
Adjusted Mean Birth Weight, g (SE)?
n
Adjusted Mean Birth Weight, g (SE)?
51,425
3,022.1 (12.9)
15,386
3,118.0 (13.3)
45,224
2,859
3,342
3,022.3 (13.0)
3,022.9 (16.4)
3,015.9 (15.9)
13,504
777
1,105
3,119.6 (13.4)
3,129.2 (23.4)
3,088.4 (20.8)
SE, standard error.
?
Covariates include: trimester enrolled in WIC; year of clinic attendance; maternal age, race, education.
?? A total of 4,715 (6.6% of study sample) women were missing data on infant birth weight.
?
Women’s exposure status is based on whether or not the clinic had been trained to deliver the 5As and whether or not the clinic was documenting its delivery of the 5As.
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442
O. Olaiya et al. / Preventive Medicine 81 (2015) 438?443
Although we were unable to measure or document how much time
was devoted to the 5As within each clinic, the 5As typically takes
5?15 min at each visit (Fiore et al., 2008). The magnitude of associations
obtained from this study compare closely with the odds of smoking cessation from counseling as reported in the USPHS practice guideline: for
minimal b3 min (OR, 1.3; 95% CI, 1.01?1.6), or low-intensity 3?10 min
(OR, 1.6; 95% CI, 1.2?2.0) counseling by a physician, and for nonphysician clinicians’ counseling (time unspeci?ed) (OR, 1.7; 95% CI,
1.3?2.1) (Fiore et al., 2008).
Though the associations in this study and other studies related to
smoking cessation counseling interventions are modest, prenatal
smoking is one of the few modi?able risk factors for which we have effective interventions to prevent several adverse pregnancy outcomes,
such as preterm delivery. In fact, in the U.S., 5%?8% of preterm deliveries
and preterm-related deaths, 13%?19% of term low birth weight deliveries, and 23%?34% of infant deaths related to sudden infant death syndrome (SIDS) are attributable to perinatal smoking (Dietz et al., 2010).
Thus, decreasing the number of pregnant women who smoke can
reduce many adverse outcomes and have signi?cant public health impacts. Among women attending Ohio WIC clinics in 2011, 20.5% (n =
56,581) smoked throughout pregnancy; smoking prevalence was
higher in rural, non-Appalachian and Appalachian counties [25.6%
(n = 17,282] (Pediatric and Pregnancy Nutrition Surveillance System,
2011). Assuming our observed associations are casual, our data suggest
that implementing the 5As in all WIC clinics statewide may help an additional 2,100 pregnant woman quit smoking annually (Northridge,
1995). Based on an Ohio expenditure per maternal smoker of $221
(using 2004 dollars), this may result in an annual savings of $464,100
in neonatal healthcare costs (Perinatal Cigarette Smoking, 2012). If associations are limited to rural, non-Appalachian and Appalachian
counties, implementation of the 5As in WIC clinics for only the areas
may help an additional 1,300 pregnant women quit smoking annually,
resulting in savings of $417,300 annually (Adams et al., Aug. 2011).
The WIC program is a uniquely advantageous setting to deliver the
5As because of the large number of low-income pregnant women it
reaches\a population with high rates of both perinatal smoking and
pregnancy-related complications (Perinatal Cigarette Smoking, 2012;
Ohio’s Commitment to Prevent Infant Mortality, 2013). For example,
the WIC program in Ohio has the potential to reach about 48% of the
pregnant population (Ohio Partners for Smoke-Free Families Final Report, 2007), and pregnant women on WIC are about three times more
likely to smoke than those not on WIC (Perinatal Cigarette Smoking,
2012). Though some pregnant women spontaneously and successfully
quit smoking when they discover they are pregnant, others are unable
to do so and may bene?t from intervention (Melvin et al., 2000;
Colman and Joyce, 2003). Studies show that women who receive
smoking cessation support expect and appreciate receiving that support
and have greater satisfaction with their care compared with those who
do not receive support (Chamberlain et al., 2013; Fiore et al., 2008).
Intensi?ed efforts to offer smoking cessation counseling to pregnant
smokers at different levels of health care delivery, both at the community level (e.g., in WIC clinics) as well as in specialized clinic settings
(e.g., obstetricians) may help to reinforce such counseling and motivate
quitting (Anon., 2010). Furthermore, cessation strategies, such as the
5As, delivered as part of a comprehensive and sustained tobacco strategy that includes smoke-free policies and higher tobacco prices/taxes are
effective in reducing smoking prevalence (WHO Report on the Global
Tobacco Epidemic, 2008; Kim et al., 2009).
Systems and implementation strategies, such as documentation of
the 5As for every client at every clinic visit, is recommended by the
USPHS to ensure that all smokers are systematically identi?ed, provided
counseling, and referred to smoking cessation resources. Documentation ensures that data are available to monitor clients’ progress. For
example, at follow-up visits, responses elicited at previous visits,
issues discussed, and action points are readily available to the health
care provider and could have been used to help reinforce steps taken
toward quitting. Finally, documentation with the FAIR form may have
served as prompts or reminders for WIC staff to initiate the 5As and
systematically move through the steps of the counseling intervention.
The use of reminder systems such as chart stickers or electronic medical
records prompts have been observed to increase the rates at which
providers implemented the 5As in clinics (Fiore et al., 2008; Levine
et al., 2013).
The strengths of this study include the availability of a census of all
low-income women in Ohio who received services from WIC during
their pregnancy from 2005 to 2011. This allowed us to compare quitting
before and after clinics were trained and account for changes in
participant characteristics over time.
Our study had limitations. First, quitting was determined based on
women’s self-report of smoking in the last 3 months of pregnancy
ascertained at the postpartum visit, thus is subject to misclassi?cation.
While non-disclosure of smoking among pregnant women has been
shown to be as high as 22% (Dietz et al., 2011), other studies, including
one conducted with WIC participants, suggest that non-disclosure may
be as low as 5% (Ross et al., 2002; Klebanoff et al., 1998; Kvalvik et al.,
2012). We assessed the difference in mean birth weight between quitters and smokers as a proxy for non-disclosure since smoking cessation
is known to increase birth weight (Chamberlain et al., 2013). Although
we observed an increase of 96 g in the adjusted mean birth weight
among women who reported quitting, this increase was modest compared with studies with cotinine-con?rmed quitting (250?300 g increase) (Li et al., 1993; Benjamin-Garner and Stotts, 2013). Thus, it is
likely that some women who reported quitting reported inaccurately
or only reduced their smoking intensity. The increase in mean birth
weight, however, was not affected by intervention participation,
suggesting that women attending a trained clinic were not more likely
to misreport smoking cessation than women in non-trained clinics.
Second, we were unable to examine the effect of varying degrees of
?delity to the 5As implementation. We used any documentation of
the 5As steps on the FAIR form as a proxy for full implementation and
therefore may have underestimated the true effect of the intervention
had it been implemented with full compliance with USPHS framework
or guidelines for smoking cessation. Third, we categorized training
and documentation status by calendar year as we did not have detailed
data on the precise month the 5As implementation and/or documentation began or terminated. Thus, it is likely that exposure status for some
women had been misclassi?ed, biasing our results towards the null.
Finally, clinics that received the 5As training were not randomly selected;
thus, our results may not be generalizable to all Ohio WIC clinics.
In conclusion, our study demonstrates that training WIC clinics to
implement the 5As and integrate the steps into their clinic ?ow may improve smoking cessation among low-income pregnant women. Given
that a number of trained clinics were not documenting use of the 5As,
there is a need to understand barriers to and support for proper documentation of the 5As to improve effectiveness. Furthermore, it is important to examine how variation in ?delity to implementation of the 5As
affects smoking cessation. Pregnancy is a time when women may
make positive behavior changes, one of which is smoking cessation;
however, many pregnant women need support to quit smoking. Training WIC clinics to deliver the 5As intervention presents an important
opportunity to help low-income, high-risk pregnant women successfully
quit smoking.
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.ypmed.2015.10.011.
Con?ict of Interest Statement
The authors declare there is no con?ict of interest.
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