HEALTHY BABIES: COLORADO COIIN Smoking Cessation Among Pregnant Women and other priorities Larry Wolk, M.D. M.S.P.H. Executive Director and Chief Medical Officer
Smoking Prevalence Among Pregnant Women with Medicaid in CO 40 35 37.7 30 25 25.2 20 15 17.1 14.8 10 5 4.1 7.1 0 Medicaid Non-Medicaid Before pregnancy During Pregnancy After delivery Colorado PRAMS, 2009-2011
Smoking Prevalence Among Pregnant Women by Race/Ethnicity 35 30 29.1 25 25.3 25 20 15 10 5 15.6 19 10.4 4.3 10.1 5.5 13.9 9.32 12.9 0 Before pregnancy During pregnancy After pregnancy White, non-hispanic Hispanic Black Other Colorado PRAMS, 2009-2011
A seven day per week bilingual Intake Call Center A comprehensive smoking history completed with a tobacco cessation coach Up to 5 proactive, motivational interviewing sessions including information on and distribution of pharmacotherapy Up to 8 weeks free Nicotine Replacement Therapy (patches or gum) for medically eligible callers Relapse prevention strategies Test messaging and email support Referrals to local cessation programs and www.coquitline.org
Colorado s Pregnancy and Postpartum Pilot (PPP) Pilot project: Colorado Developed out of a need to serve a priority population Goal: Develop and implement a coaching protocol for pregnant women that encourages postpartum maintenance of abstinence 6
Colorado QuitLine Pregnancy & Postpartum Program Dedicated Coaching (5 calls during pregnancy) (4 calls during postpartum) English and Spanish speaking coaches Nicotine Replacement Therapy MD consent required Smoking Cessation Prescriptions Incentives Based on completed calls Websites Mobile Apps Texting Educational Materials 7
PPP Outcomes 70 70 60 55.2 50 42.9 40 30 28.8 24.9 PPP group All callers 20 10 0 TF (end of pregnancy) TF (7 mos PP) Relapse 8
Citywide smoking ban in one community provided a natural experiment
Methods Observation time period Pre-ban observation - April 1, 2001 to July 1, 2003 Post-ban observation April 1, 2004 July 1, 2006 Number of births studied 6,717 in the City of Pueblo 32, 293 in El Paso County
Smoking ban was associated with improved birth outcomes Birth outcomes in Pueblo showed significant reduction in the odds of: Maternal smoking (38%) Pre-term births (23%) The odds of Low-Birth Rate babies decreased by 8% (not statistically significant) Birth outcomes in El Paso County showed no such drop during the same time period. The study suggests that smoking bans have a significant and immediate positive impact on the health of infants and mothers.
Statewide study on Low Birth Weight 2000 & 2010
2010 Compared to 2000 Results (2007-2009 Compared with 1995-1997 Birth Data
Current Efforts in Colorado Colorado QuitLine Pregnancy/Postpartum Protocol Baby & Me Tobacco Free Program Face to face cessation counseling and carbon monoxide testing for low-income pregnant women Health Communications and Systems Change Health care providers: promo kits, QL referral, training Pregnant women: promote available services & benefits Smoking Bans in Multi-Unit Housing Reduces exposure to secondhand smoke and promotes cessation and prevents initiation
Implications of ACA & Future Opportunities Increase Medicaid cessation benefit utilization Promote QL services & cessation benefits to pregnant women, increase Medicaid reimbursement claims for cessation Affordable Care Act: define comprehensive cessation benefits under state exchange and employer plans Exchange: Must cover EHB, but cessation benefit is undefined Employer-Sponsored: New plans must cover tobacco Tx, but coverage varies widely plan to plan Engage Maternal and Child Health providers Integrate cessation strategies with CO CoIIN efforts, existing perinatal interventions with WIC, Prenatal Plus, Family Planning, Maternal Child Health and Home Visitation programs
Deaths per 1,000 live births Infant Mortality in Colorado African American infants in Colorado die at more than twice the rate of White, non-hispanic infants. Figure 2. Major causes of infant mortality, Colorado, 2013 15.0 10.0 5.0 0.0 Figure 1. Infant mortality rates by race/ethnicity, Colorado, 2013 5.1 All 4.0 White, non- Hispanic 7.9 White, Hispanic Race/Ethnicity 10.3 Black/African American 3.6 Asian American/Pacific Islander 4.1 American Indian/Native Alaskan 9% 10% 7% 5% 4% 26% 38% Prematurity and related conditions Congenital anomalies Other perinatal conditions SIDS and SUID All other causes Injury The primary cause of infant death in Colorado is prematurity and related conditions. Source: Colorado Vital Records, CDPHE
Colorado CoIIN VISION: Colorado 4.0 - Each and every baby celebrates a first birthday. AIM: Reduce Colorado s African American infant mortality rate to the current White, non-hispanic rate (4.0/1,000) or below by employing complementary strategies at both the state and local level. STRATEGIC PRIORITIES 1. Expand the content and increase the quality of preconception/prenatal/ postpartum interventions. 2. Address the impact of social determinants of health. 3. Improve the capacity of women and families to protect and promote their health.
Colorado CoIIN Strategies State and local strategies will be coordinated at each level of the health impact pyramid. State strategies include PTB medical guidelines, quality collaboratives, RCCO partnerships, LARC, familyfriendly policy creation. Local strategies include Centering prenatal care, increased service utilization (WIC, LARC, Quitline, breastfeeding support), culturally-informed care.
Promoting LARC Increased LARC use by more than 400% Correlation with positive health outcomes 40% drop in teen birth rate >50% drop in second and higher order teen births 18% drop in birth rate for women 20-24 35% decrease in the abortion rate for women 15-19 and 18% decline in women 20-24 23% decrease in WIC enrollment 20% decline in infant mortality*
Tobacco and Marijuana Clean Air Act applies to marijuana Not clear how marijuana legalization will impact tobacco use or cessation No/limited data on dual use and substitution between the products Electronic devices can be used for both marijuana and tobacco mechanism of the devices is identical Vape pens used for marijuana E-cigarettes used for tobacco No way to tell if an e-device contains marijuana or tobacco liquid
Questions? Larry Wolk, MD MSPH larry.wolk@state.co.us 303-692-2012