Does adopting a prenatal substance use protocol reduce racial disparities in CPS reporting related to maternal drug use? A California case study.

OBJECTIVE: This study examined whether adopting a standardized prenatal substance use protocol (protocol) in a hospital labor and delivery unit reduced racial disparities in reporting to child protective services (CPS) related to maternal drug use during pregnancy. STUDY DESIGN: This study used an interrupted time series design with a non-equivalent control. One hospital adopted a protocol and another hospital group serving a similar geographic population did not change protocols. Data on CPS reporting disparities from these hospitals over 3.5 years were analyzed using segmented regression. RESULT: In the hospital that adopted the protocol, almost five times more black than white newborns were reported during the study period. Adopting the protocol was not associated with reduced disparities. CONCLUSION: Adopting a protocol cannot be assumed to reduce CPS reporting disparities. Efforts to encourage hospitals to adopt protocols as a strategy to reduce disparities may be misguided. Other strategies to reduce disparities are needed.

Alcohol and drug CAGE screeners for pregnant, low-income women: the California Perinatal Needs Assessment.

The purpose of this study is to evaluate a revised CAGE and a new drug version of the CAGE as screeners for risk of heavier or problem alcohol and/or drug use among a population of low-income, pregnant women and adolescents (n = 1147) recruited from 19 agencies in two California counties. Two versions of the CAGE were used in this analysis: (1) the 4-item Alcohol CAGE, using the year before knowing about pregnancy as the timeframe (as opposed to lifetime prevalence), and (2) a newly developed 4-item Drug CAGE using the same timeframe. The two instruments were assessed on sensitivity, specificity, and area under the receiver operating characteristic curve by using self-reported periconceptional heavier or problem alcohol and drug use as the criteria for the 12 months before knowing about the pregnancy. The results indicate that, for the Alcohol CAGE, the cut-point of 1 yielded the highest sensitivity, while maximizing sensitivity and specificity (receiver operating characteristic analysis) for this sample. For heavier drug use, the Drug CAGE had a high sensitivity rate with a cut-point of 3. The Drug CAGE was not a useful screener for periconceptional lighter drug and marijuana use. These results demonstrate the utility of a revised version of the Alcohol CAGE that incorporates a more specific timeframe (the year before pregnancy) to screen pregnant, low-income women for at-risk heavier or problem alcohol use. The Drug CAGE, which uses the same timeframe, seems to be an effective tool for identifying pregnant, low-income women at risk for heavier drug use only. More psychometric works needs to be done to refine the Drug CAGE for detecting at-risk use of lighter drugs and marijuana.

Perspectives of pregnant substance-using women: findings from the California Perinatal Needs Assessment.

This article reports on selected major findings of a study on alcohol and drug use patterns and problems and unmet service needs, drawing on interview data from a sample of substance-involved pregnant women who were clients at public health, social service, and criminal justice agencies in two California counties. Based on screening rates, a sizable group of pregnant agency clients regularly used alcohol and other drugs, particularly marijuana and cocaine, and most of these users had not been in substance abuse treatment. Reported use of alcohol and other drugs diminished considerably during pregnancy. Negative consequences of alcohol and drug use, problems with family and friends' substance use, neighborhood alcohol and drug problems, and substance-related violence were widely experienced. The greatest service needs include job placement, educational programs and housing. Prenatal health care was widely received, although often inconsistently or late in the pregnancy. Despite high treatment satisfaction among those in recovery programs, relatively few women desired formal treatment. These findings, which are consistent with those of other recent studies, suggest the complexity of problems and needs among substance-involved, low-income pregnant and parenting women.

Quitting smoking: reasons for quitting and predictors of cessation among medical patients.

OBJECTIVE: To describe why medical patients quit smoking and the methods they use. DESIGN: Cross-sectional and prospective cohort design. Patient smokers were enrolled in a study of physician counseling about smoking. One year later, 2,581 of the patients were asked about quit attempts and methods used. Of those, 245 former smokers whose quitting had been biologically validated were interviewed about why and how they had quit. SETTING: Offices of internists and family practitioners in private practice and a health maintenance organization. SUBJECTS: Consecutive sample of ambulatory patients who smoked. MEASUREMENTS AND MAIN RESULTS: Baseline questionnaires included demographic data, smoking history, and symptoms and diagnoses related to smoking. After one year, subjects were interviewed about smoking status and methods used in attempting to quit. Cessation was confirmed by biochemical testing. Those who had quit were asked about reasons for quitting. Seventy-seven percent of successful quitters gave health-related reasons for quitting and the quitters ranked "harmful to health" as the most important reason for quitting. In a multivariate analysis, those who had a college education, who had social pressures to quit, and who had greater confidence in being able to quit were more likely to have quit smoking one year later, while those who smoked their first cigarette within 15 minutes of awakening and who had more diagnoses related to smoking were less likely to have quit smoking one year later. Participation in a treatment program and having been counseled by a physician or nurse practitioner were positively related to successful quitting, while use of filters or mouthpieces was negatively related. CONCLUSIONS: Concerns about health are the most common reason patients give for quitting, and addiction is the most important barrier to quitting. Education, social pressure, provider advice, and formal programs, but not over-the-counter devices, appear to increase the chances that smokers will quit.

Counseling medical patients about cigarette smoking: a comparison of the impact of training on nurse practitioners and physicians.

Health providers believe that eliminating smoking is an important health promotion goal, but physicians and nurse practitioners may differ in the implementation of that belief. To determine whether nurse practitioners or physicians were more likely to counsel smokers to quit smoking, 12 internal medicine nurse practitioners (100 percent female) and 40 internal medicine physicians (30 percent female) were studied at four San Francisco Bay-area Kaiser Permanente Medical Centers, both before and after training in smoking-cessation counseling. In addition, exit phone surveys of at least 15 smokers per participant were completed as soon as possible following an office visit to the participant (269 nurse practitioner patients; 948 physician patients). It was found that nurse practitioners discussed smoking with patients more often than did physicians (64 percent vs. 50 percent; p less than 0.001), asked patients more often whether they were interested in quitting (49 percent vs. 40 percent; p less than 0.01), distributed more smoking-cessation literature to patients (37 percent vs. 25 percent; p less than 0.001) and made more follow-up appointments about smoking (36 percent vs. 19 percent; p less than 0.001). These differences in counseling behavior between the two groups were not explained by differences in patient characteristics of the two groups. The authors concluded that, given the same training, nurse practitioners are more likely to counsel smokers about quitting than are physicians.

Training physicians in counseling about smoking cessation. A randomized trial of the "Quit for Life" program.

STUDY OBJECTIVE: To test whether physicians who receive a continuing education program ("Quit for Life") about how to counsel smokers to quit would counsel smokers more effectively and have higher rates of long-term smoking cessation among their patients who smoke. DESIGN: Randomized trial with blinded assessment of principal outcomes. SETTING: Four health maintenance organization medical centers in northern California. SUBJECTS: Eighty-one internists assigned by blinded randomization to receive training (40) or serve as controls (41). Consecutive samples of smokers visiting each physician (mean, 25.6 patients per experimental and 25.2 per control physician). INTERVENTIONS: Internists received 3 hours of training about how to help smokers quit. Physicians and their office staff also were given self-help booklets to distribute free to smokers and were urged to use a system of stickers on charts to remind physicians to counsel smokers about quitting. MEASUREMENTS AND MAIN RESULTS: On the basis of telephone interviews with patients after visiting the physician, we determined that internists who attended the Quit for Life program discussed smoking with more patients who smoked, spent more time counseling them about smoking, helped more patients set dates to quit smoking, gave out more self-help booklets, and made more follow-up appointments to discuss smoking than did internists in the control group. One year later, the rate of biochemically confirmed, long-term (greater than or equal to 9 months) abstinence from smoking was 1% higher among all patients of trained internists than among patients of controls (95% CI, -0.1% to +2.3%), and 2.2% (+0.2% to +4.3%) higher among the patients who most wanted to quit smoking. CONCLUSIONS: This continuing education program substantially changed the way physicians counseled smokers. As a result, a few more patients who wanted to quit smoking achieved long-term abstinence.

Dentists as smoking cessation counselors.

Dentists can help people quit smoking because they are experts in oral health, are accustomed to counseling about oral preventive health, and have broad exposure to the general populace. To determine dentists' counseling practices with regard to smoking cessation, a randomly selected sample of 82 dentists practicing in the San Francisco Bay Area were surveyed. Also 106 internists in the same region were surveyed. Whereas the dentists believed smoking is dangerous to health and considered counseling as an important part of their practice, only 17%, compared with 58% of the internists, frequently discussed quitting with their patients who smoke. The two groups also differed in the types of counseling they used. Dentists attributed their lack of counseling to poor insurance coverage, insufficient time, lack of training, and fear that patients might leave their practices if urged to quit. These issues must be addressed if dentists are to participate fully in helping their patients quit smoking.