Labor of Love Summit-Helping Indiana Reduce Infant Mortality The Indiana Tobacco Quitline & Local Community Partner Efforts

Tobacco Use Burden on Indiana 9,700 deaths/annually More than 1 in 4 adults smoke (22%-2013) For every death, two new youth start and 20 are living with a chronic disease $2.08 billion in annual health care costs $487 million in Medicaid costs Indiana taxpayers pay $566 per household to treat tobacco-related disease For every pack of cigarettes sold in Indiana, it spends $15.90 in health care costs related to tobacco

Smoking during pregnancy is associated with poor health outcomes Twenty to thirty percent (20-30%) of the cases of low birth weight babies can be attributed to smoking. Women who smoke during pregnancy have more than twice the risk of delivering a low birth weight baby. Babies of mothers who smoked during pregnancy have twice the risk of SIDS than infants of nonsmoking mothers. Women who smoke have a higher incidence of ectopic pregnancy. Pregnant smokers also have a 30-50% higher risk of miscarriage than nonsmokers. Prenatal exposure to secondhand smoke is also harmful to a child’s mental development. Children of mothers who were exposed to secondhand smoke when pregnant have lower scores on cognitive development tests at age two, compared to children of mothers living in smoke free homes during pregnancy. Pregnant smokers who are ready to quit should know that it's never too late to quit smoking during pregnancy. Many pregnant women are tempted to cut down the number of cigarettes they smoke instead of quitting, but quitting entirely is the best thing a pregnant woman can do for themselves and their baby. The benefits of quitting smoking can be seen immediately. After just one day of not smoking, the baby will get more oxygen. While women experience withdrawal symptoms, these are often signs that the body is healing. They are normal, temporary, and will lessen in a couple of weeks. Quitting will increase the mother’s energy levels and help make breathing easier.

Smoking during pregnancy <=10% 11-20% 21-29% 30+% Indiana overall: 16.5% County rates overall: 3.9 % to 33.9% Medicaid Members: 27.0% Out of 84K live births, approximately 14K are smoking-affected births, or births to mothers who smoked during pregnancy The rate of Indiana mothers who reported smoking during pregnancy is considerably higher than the national average of 10.7%. Even more alarming are rates in Indiana counties that exceed state and national rates. The table above lists Indiana’s counties along with the percentage of mothers who reported smoking during pregnancy (2011 birth certificate data). • County rates range from 3.9% to 33.9%. • Thirty-nine (39) of Indiana’s 92 counties have a smoking during pregnancy rate significantly higher than the Indiana average of 16.5%. Indiana vs. US – 16.5% vs. 9.1% Medicaid range from 17.7% to 55.8% Stresses the importance of reaching pregnant women but also women of child-bearing age (15-44) to take the broader approach to promoting smoke-free pregnancies and awareness for healthcare providers to be having these discussions. 2012 Indiana Natality Report

What is a Quitline? Telephone-based Cessation Services Offered Toll-free Evidence-based Proactive Coaches Highly trained in cognitive behavioral therapy 240 hours of training Spanish speaking competency (170 other languages) Educated up to graduate level Over 50% with 3+ years prior experience in counseling The Indiana Tobacco Quitline is staffed with trained dedicated Quit Coaches® who have helped hundreds of people quit using tobacco. A trained Quit Coach® is assigned to work with individuals to provide solutions tailored for each quitter’s needs. A Quit Coach® will guide quitters through the process of breaking their tobacco addiction. When tobacco users are ready to quit, the Quit Coach will assist in making a quit plan for each individual trying to quit.

The Program 4 prearranged calls w/coach 10 prearranged calls for pregnant woman (special program) 5 prearranged calls for youth Unlimited Web coaching Unlimited call in privileges and access to coaches Free 2-week NRT starter kit (uninsured, Medicaid, Medicare) Stage-based Support Materials

Special Help for Pregnant Women The Indiana Tobacco Quitline offers special services for pregnant women 10 call protocol Woman-centered approach: emphasizing benefits of quitting to mother and fetus Encourages smoking partners to quit as well  The program will take a woman-centered approach, balancing the benefits of quitting for both the fetus and the woman. Discuss identity as a woman separate from being an expectant mother.   Address the health risks of continued smoking to the mother and fetus, and emphasize the health benefits of quitting for both. We will validate efforts to cut down on the number of cigarettes smoked per day, while continuing to emphasize complete abstinence as the ultimate goal. While cessation during pregnancy has important and specific health relevance for the fetus, protocols designed to emphasize the importance of remaining quit beyond delivery will be incorporated into the program, with at least two postpartum interventions (so more services to pregnant women during and after pregnancy through one-on-one telephone counseling). Exposure to Second-Hand Smoke (SHS) is a major health risk to the baby (asthma, ear infections, SIDS, etc.) and sustaining cessation beyond delivery is equally important to the health of the mother. To this end, motivational messages and protocols to problem-solve barriers to sustaining abstinence will be incorporated into the intervention content. Quit Coaches will provide information about pharmacotherapy options specific to pregnant women. The intervention will seek to educate women to engage meaningful discussion with their physicians about the pros and cons of using pharmacotherapy to aid their cessation effort. Numerous articles have emphasized the important role that spousal/partner support can have in helping a pregnant smoker successfully quit. The proposed program will incorporate an element to enlist optimal support for the woman and to encourage smoking partners to quit as well. Importantly, Quit Coaches will be supportive of and empathetic with pregnant smokers. Pregnant smokers often have some guilt about their smoking and the harm it may cause their babies. Added to the fact that many pregnancies are not planned or perhaps wanted, the pregnant smoker may already be facing significant challenges. Training for Quit Coaches providing treatment to pregnant smokers will emphasize these elements. Quit kit materials designed to meet the needs of pregnant smokers will be incorporated into the program design. These materials (Need Help Putting Out That Cigarette?) will meet the literacy needs of the target population and are currently being provided to pregnant woman. Assess whether the caller has a partner. Factors to be considered in this aspect of treatment includes: Not assuming the partner is male Not assuming the partner is supportive about the pregnancy Not assuming the partner is supportive about her quitting smoking Smoking partners/spouses will be encouraged to enroll in the standard 5-call program, with access to NRT, since there is good evidence that a smoke-free spouse/partner increases quit outcomes by pregnant smokers. Program will include: Up to 10 calls with relapse prevention sensitivity. The first 5 – 6 calls will be completed within 60 to 90 days of enrollment. One call will be delivered 30 days prior to the planned due date. Will include two postpartum contacts (15 days and 45 days postpartum) Structured content for pregnant smokers in Contemplation. The Quit Coach is there during those tough times when a pregnant smoker may be tempted to smoke and the registrant always can the call the quitline anytime even just for encouragement. It is important for healthcare providers to be aware of this special program and refer pregnant women to this option. They may not use all ten calls but they at least have that option free to them. It is toll free, accessible 24/7 so why not use this enhanced option during their pregnancy to stay quit. There is actually a reach of ~25% of total callers were the women of childbearing age. Of the 10,839 callers during the last SFY 2014, ~2,600 were the women of childbearing age. SO we are reaching this population and its important to continue to reach this population.

The ITQL Participant Experience 1. Fax Referral or Person Calls 3. Professional Coach 2. Intake Specialist 3. Professional Web Coach 4. Physician RX or OTC

The Program Works Practices based on 25 yrs of research helped hundreds of thousands of smokers quit & stay quit Quit at personal pace Conquer urges to smoke Use Pharmaco so they really work Don’t just Quit, become NON-SMOKER Choose own Quit Date, personal Quit Coach help prepare & get ready Learn when & where urges strike & how to cope & manage stress w/o smoking Recommend meds right for each participant and teach how to use correctly QUIT for good-support to make this the LAST Quit, help with weight issues

Something for Everyone

Plus Recommend a Medication, If Appropriate Brief Intervention ASK Do you use tobacco? ADVISE Quit tobacco products! REFER 1-800-QUIT-NOW Plus Recommend a Medication, If Appropriate Everyone ~ every patient Routinely ~ every visit Non-judgmentally Clear, Strong, Personalized Clinicians advise every patient WILLING TO MAKE A QUIT attempt to use counseling treatments (ITQL) and recommended medications To the Indiana Tobacco Quitline1-800-QUIT-NOW (1-800-784-8669) Share other cessation services in your community—if available Help build their interest in receiving the Quitline counseling

Promoting Smoke free Pregnancy in Indiana (PSPI) is a statewide coalition (partner of TPC) that has the primary objective of reducing the prevalence of smoking among pregnant women and women of child-bearing age. The coalition supports promoting cessation and the Indiana Tobacco Quitline to women; provides online resources and connects healthcare professionals to treatment resources; provides live and online training to improve treatment of tobacco use during pregnancy to professionals; and provides positive-themed messaging supporting smoke free pregnancy. PSPI and local partners help emphasize the role of the HC provider, PSPI specifically focuses on provider resources, training and technical assistance.

Conclusions Treatment of tobacco use needs at least same attention that other chronic diseases demand Health Care Providers are encouraged to: Engage in effective behavioral interventions (AAR) Optimize medication use Know they have the most credibility w/patients ITQL Referral/Preferred Network is one KEY component of a multi-faceted approach to decreasing Infant Mortality in Indiana. We know IM is a priority area for ISDH moving forward. We have the evidence-based resource to help provide necessary support to this population and we should be spreading awareness and educating on this service to help reduce IM. (by helping the pregnant woman and her baby) Every provider should be educated and trained on the ITQL, both regular program and 10 call program. Again, its free, accessible 24/7. But it’s an important component and needs to be utilized! (other components = Policy change (SF air campaigns at county level, TF campus policies), Increase on taxation/Regulation of products, Cessation systems provider, employer & organization, Decrease in youth engagement, Increase partnerships and continue to build coalition)

Fountain and Warren Counties Community Baby Shower Fountain and Warren Counties

Fountain and Warren County Demographics No Obstetrians or Gynecologists in either county. Nearest hospitals for deliveries are in Tippecanoe County or in the State of Illinois (Danville). Fountain County – 2013 estimated population 16,880 Median household income $45,919 (11.7% below poverty) 2008-2012 Warren County – 2013 estimated population 8,415 Median household income $51,504 (9.4% below poverty) 2008-2012 2012 Percent of mothers who reported smoking during pregnancy: Fountain County 23.3% Warren County 30.9% Indiana State Average 16.5%

Morning breakout session on Lead Poisoning Prevention-included latest information on consumer products alerts and harm of lead-based paints.

Morning breakout session about the Indiana Safe Sleep Program-attendees of education session received a Pack n Play after demonstrating how to correctly set it up.

Morning break out session on Tobacco Use During Pregnancy, Exposure to Secondhand Smoke, and Thirdhand Smoke.

MDwise is explaining the various health plans available

Two displays providing information about Poison Safety and Immunizations.

Display representing the services available through Head Start and Early Head Start

Display about healthy relationships and domestic violence.

Display about the services offered through the Healthy Families program.

Display about the First Steps program.

Healthy lunch provided to attendees featuring Text for Baby

Demonstration of proper infant/child CPR techniques during lunch time

Information about Car Seat Safety during an afternoon break out session.

WIC presented information about the Benefits of Breastfeeding during an afternoon break out session.

Afternoon break out session about Nutrition.

This is why we do what we do!

Questions Thank you for your participation!!!!! Brian Busching Regional Program Director/Cessation Systems Specialist Tobacco Prevention and Cessation Commission, Indiana State Department of Health bbusching@isdh.in.gov 317-234-2439 Kathy Walker Program Director Fountain/Warren Tobacco Prevention & Cessation Program 765-793-4881