MSS Policy and Procedure Manual
Risk Factors and Minimal Interventions – Tobacco Use and Secondhand Smoke Cessation/Reduction

Addressing tobacco usage and exposure should be a brief part of every visit.

Screen/Assess:

• Ask the client about her past and current tobacco use
• Ask the client about her current exposure to secondhand smoke, and about the environment(s) where the baby will be.
• Evaluate her readiness to change by using the following Stages of Change scale:

Not Ready to Quit: Has no intention to quit within the next six months.

These clients may be uninformed of the dangers of tobacco. They may use tobacco as a coping mechanism. They may be unprepared or unwilling to deal with nicotine withdrawal symptoms. They may have been trying to quit, been unsuccessful and unwilling to try again at this time.

Thinking About Quitting: Intends to quit within the next six months.

These clients have reasons to quit and reasons to keep smoking. They are aware of risks associated with their tobacco use, but are not ready to make a commitment to quit.

Ready to Quit: Is willing to set a Quit Date within the next 30 days.

Quitting: Has remained tobacco-free for less than six months.

Staying Quit: Has remained tobacco-free for more than six months.

These clients have already quit and are learning to live without tobacco. During this stage, relapse is still a danger.

Relapse: Is using tobacco again after a period of being tobacco-free.

Relapse is common, especially among postpartum women: 79-90% return to smoking within one year after delivery. Women often relapse due to the stress of the baby and as they return to their former social activities.

Educate/Counsel:

• Tobacco education posters, tabletop signs, and other visible messages create an environment that makes asking about tobacco use a normal and expected part of a visit.
• If the woman is a pregnant/postpartum smoker, provide additional information tailored to her, including the American Cancer Society’s magazines, Make Yours A Fresh Start Family.
• Depending upon her stage of change, offer the appropriate information, messages, handouts and assistance.
• Example for a client contemplating change: “As your provider, I need you to know that quitting smoking is the most important thing you can do to protect the health of your unborn baby. If you are thinking of quitting at this time, I can help you get started.”
• Depending upon her situation, offer information about ways to eliminate secondhand smoke exposure and offer assistance that will support changes. For example: “It is OK to encourage people to smoke outdoors, which is a good way to protect you and your baby from secondhand smoke”.

Intervention:

• Determine the client’s willingness to make a quit attempt at the present time (for example, within the next 30 days).
• If the person is willing to make a quit attempt, provide assistance setting a Quit Date.
• If the person clearly states an unwillingness to make a quit attempt at the present time, you can offer support and appropriate information to get the person thinking about quitting.
• Client-specific information on tobacco use, secondhand smoke exposure, and assistance provided and recording of progress and outcomes should be documented in each client’s chart, as required in the Tobacco Cessation During Pregnancy Performance Measure.
• Case Conference with team members
• Help the client develop coping skills

Surveillance - Monitor, follow-up, and Ongoing Assessment

Follow-up may be as simple as an invitation to talk about quitting in the future. Or follow-up may be arranged for a specific time, such as when a pregnant woman returns for an appointment, or when the provider returns for a home visit. It is particularly important to arrange follow-up contact with a tobacco user who is making a quit attempt. Whenever possible, arrange the follow-up within a week after the individual’s Quit Date.

During the follow-up contact:

• Ask about tobacco status.
• Congratulate individuals who are tobacco-free and support them in staying quit.
• Support people who have relapsed and help them in making a new quit attempt.
• Develop with the client, a post-pregnancy plan addressing the following:
• How to remain tobacco free, or
• How to continue to reduce tobacco use.
• Keeping the newborn free from exposure to secondhand smoke.
• Support systems that are available to the client; e.g. Medical referral, Community resources, Washington State Quit line, Secondhand smoke materials, WIC, other.
• Document outcomes on the care plan, and if no changes occurred since the risk factor was identified note why.

This risk factor is one of the performance measures. When recording outcomes on the discharge summary, you are allowed to bill for completing the information for this risk factor. Additional information is available in the MSS/ICM Billing Instructions.