Using the Postpartum Hospital Stay to Address Mothers' and Fathers' Smoking: The NEWS Study

Design

This study tested the feasibility and efficacy of a system-level intervention in a postpartum obstetric unit. Parents who smoked or had recently quit were identified systematically, enrolled in the study, and linked to quitline support. The Massachusetts General Hospital Human Subjects Committee approved this study.

Participants

Participants were recruited from among the parents of newborns who were delivered at Massachusetts General Hospital during a 14-month recruitment period from February 2005 through April 2006. After a routine delivery mothers are admitted to the postpartum floor for the remainder of their hospital stay (typically 48–72 hours). As part of the admissions process, an obstetric nurse practitioner meets with each mother to perform a routine postpartum checklist. For the study, we added to this checklist a question asking, “Has either parent/guardian smoked a cigarette, even a puff, within the last 12 months?” The nurse practitioner recorded the smoking status of both parents in the mother's medical record. With a positive answer, the nurse gave each parent an educational pamphlet about SHS exposure and the “importance of not smoking around your infant” and contact information for the state quitline.

Nurse practitioners were trained for 2 weeks to make this assessment. The accuracy of their assessments was validated for two 1-week periods. Each week, study staff themselves assessed the smoking status of both parents and then compared their results with the results obtained by the nurse practitioners. Agreement was high (κ = 0.90).

A master's-level research assistant screened the charts of new admissions to identify potentially eligible parents on the basis of the nursing question that had been added to the checklist described. A parent was eligible when he or she reported being a current smoker (defined as having smoked, even a puff, within the last 30 days) or a recent quitter (operationalized as having smoked, even a puff, 1 month before this pregnancy). We operationalized recent quitter in this way to capture all quits during pregnancy given uncertainty around the actual date of conception. Other eligibility criteria included having access to a telephone, speaking English, and expectation of being a Massachusetts resident throughout their study participation (∼3 months from consent date). Eligible parents were invited to enroll, gave informed consent, and completed a baseline survey administered by the research assistant. We conducted with the parents who enrolled in the research study follow-up telephone surveys at 3 months after discharge from the hospital.

Randomization

Participants were assigned to either the control or the intervention condition on the basis of the date the mother was admitted to the postpartum floor. This strategy was chosen to permit greater predictability of workflow for the research assistant. Before the start of participant recruitment, each date during the recruitment period was randomly designated as control or intervention condition. A study staff member flipped a coin while another staff member recorded the result of the flip (heads or tails) on a piece of paper. Each piece of paper was sealed in an envelope with a recruitment date written on the front of it. A third staff member, who was not part of the coin-flipping process, decided whether heads or tails would be intervention days. On the morning of each recruitment day, a member of the study staff took the envelope for that date and opened it to reveal that date's group assignment. Participant recruitment occurred Monday through Saturday.

Survey Measures

The primary measure of cessation was 7-day point prevalence of cotinine-verified tobacco abstinence at 3 months' postpartum. The baseline saliva sample was collected from all participants after the administration of the baseline survey to compare self-reported abstinence with laboratory evidence. At the 3-month follow-up, the study participants who reported a 7-day abstinence were mailed a package with a tube (cotton insert), a biohazard plastic bag, an instruction sheet, and return-addressed, stamped envelope. We used a monetary incentive ($50) and multiple contacts to obtain mailed cotinine samples at 3 months. Self-reported nonsmoking was considered validated when saliva cotinine value was <20 ng/mL by using the enzyme-linked immunosorbent assay method.¹⁵ As an additional intermediate survey outcome measure, we compared percentage of parents who reported quit attempts that lasted 24 hours in intervention and control time periods at the 3-month follow-up.¹⁶

Measures and covariates included demographics, smoking history, smokers in household, social supports, and satisfaction with intervention components. These variables were assessed at baseline and follow-up by using items drawn from the Smoke-Free Families Core Assessment Forms,¹⁶ HEDIS Measures Interview Survey,¹⁷ and our previous work.¹⁸ In the analysis, baseline smokers and quitters were analyzed separately and then combined to yield an overall effect size. All parents who were lost to follow-up were assumed to be smoking, a conservative intention-to-treat analysis. A stratified analysis of the fathers was also performed. Small sample sizes in individual cells did not support multivariable analyses.

Intervention

Parents who were assigned to the control condition had no contact between the baseline and follow-up surveys. Parents who were assigned to the intervention condition received the following: (1) one 15-minute in-person counseling session delivered by trained study staff working from adapted materials and messages specifically tailored for parental smokers (www.ceasetobacco.org)^18,19; (2) offer of enrollment in a proactive state-of-the-art telephone counseling intervention (QuitWorks, the Massachusetts statewide quitline, which did not offer nicotine replacement therapy [NRT] at the time of the study); and (3) letters faxed to the newborn's pediatrician, parents' primary care provider, and mother's obstetrician indicating the parent's tobacco use status and readiness to quit and recommending useful strategies to facilitate parental cessation, the need for ongoing support, and medication prescription when appropriate. The overall strategy is based on the evidence-based 5A model and tailored to the circumstances of the parental smoker in the hospital setting when their child is hospitalized.^7,19,20

Parents who accepted quitline referral completed a QuitWorks enrollment form, which was faxed to the state quitline. Quitline staff then made up to a total of 5 attempts to reach the parent by telephone. If they were unable to make contact with the parent, then they sent written cessation materials by mail to the parent. When they did reach a parent, they conducted a brief telephone interview to assess readiness to quit or willingness to remain abstinent and helped the parent to decide on a course of action, including intensive telephone counseling and/or referral to a local tobacco treatment service in the community. A telephone line of quitting tips and a Web-based cessation program were also offered. The outcome of this session was reported to the parent's designated provider, in this case the pediatrician, by a faxed feedback report from the quitline. The rationale is that parents see the child's physician more often than their own physicians during the child's first year of life. Parents who decline proactive quitline enrollment were encouraged to discuss quitting options with their health care provider, given the Massachusetts quitline contact information, and encouraged to call.