University of Alabama at Birmingham- School of Education

Program Goals

From 1981 to 1997, the Smoking Cessation and Reduction in Pregnancy Program (SCRIPP) has been conducted among Medicaid-eligible women in Alabama public health prenatal care clinics to reduce smoking prevalence rates and to significantly increase cessation and significant reduction rates.  Two randomized clinical trials (1981-1991) conducted among this high-risk, disadvantaged population have evaluated a standardized program of cessation skills and risk counseling appropriate for use in routine prenatal care.

Program Features

This multi-component health education program, based on social learning theory, was developed in consultation with patients and clinic staff (physicians, nurses, social workers, and nutritionists).  The materials are culturally sensitive and were tested by qualitative and quantitative evaluations of cohorts who were approximately half African American.

During the first routine prenatal care visit, a trained health counselor teaches standardized cessation methods and provides risk counseling using A Pregnant Woman’s Guide to Quit Smoking.  A supportive video component has been added.  Systemic reinforcement is provided by clinic staff.  Program effectiveness, cost effectiveness, and estimated cost benefit of the methods to the annual state and US birth rate cohort (1990-2000) have been evaluated.

Evaluation studies for SCRIPP included 94% of the Medicaid-eligible pregnant smokers in Birmingham-area county prenatal health clinics.  Behavioral impact and cost-effectiveness analyses, supported by the National Institutes of Health, have been performed (Abstracts #1, #2, #3).  SCRIPP increases normal patient quit rates (Q) and significant reduction rates (SR) from 2% (Q) to 14%-20% (Q) and from 7% (SR) to 18%-30% (SR).

The estimated cost benefit of dissemination to the Alabama Medicaid obstetrical cohort has been assessed (Abstract #3).  The potential behavioral impact of dissemination of these methods to the annual US birth cohort (Abstract #5) and associated clinical impact and excess health care costs for the 1990 decade have been evaluated (Abstracts #6, #7, #8).  Prevalence surveys by the Centers for Disease Control and Prevention identified substantial reductions in smoking rates among Alabama’s Medicaid-supported public prenatal patients:  white, 50% (1985) to 32% (1995); black, 25% (1985) to 7% (1995).  Two comprehensive meta-evaluations of smoking and pregnancy intervention studies confirm that SCRIPP is effective for Medicaid patients (Abstracts #4 and #8).

According to the Institute of Medicine, every low birth weight infant averted saves $12,000 to $30,000 (1990 discounted inflation-adjusted estimate).  Sensitivity analyses applied to the annual Alabama and US Medicaid cohort indicate that for every $1 spent on SCRIPP smoking cessation methods for pregnant women, as estimated $7 to $17 in medical costs may be saved (Abstract #4). This cost reduction does not include the long-term direct and indirect emotional impact incurred by the family.  SCRIPP is one of the most efficacious and cost- effective methods available to achieve the Healthy People 2000 managed care health and tobacco prenatal goals for pregnant smokers.

SCRIPP has also been tested and evaluated in North Carolina (Abstract #10), Florida, Michigan (Mayer 1990), Montana, Ohio, Kentucky, Massachusetts, and Washington, DC (Coates 1991), as well as in Sweden (Valbo 1991), Norway (Hjalmarson 1991); Australia and multiple Canadian provinces (O’Connor 1992).  The program is also being used by Healthy Start in Birmingham.  In 1996, a Robert Wood Foundation dissemination expert panel identified SCRIPP as one of five national programs recommended for routine use in prenatal care as "a best clinical practice method for pregnant smokers."

References

Coates, D., Maxwell, J. (1990)  Lessons learned from the better babies project.  March of Dimes Birth Defects Foundation:  White Plains, NY.

Mayer, J., Hawkins, B., Todd, R. (1990)  A randomized evaluation of smoking cessation interventions for pregnant women at a clinic.  American Journal of Public Health (80)76-78.

Windsor, R., (1990)  The handbook to plan, implement and evaluate smoking cessation programs for pregnant women.  March of Dimes Birth Defects Foundation:  White Plains, NY.

Hjalmarson, A.I.M., Hahn, L., and Svanberg, B. (1991)  Stopping smoking in pregnancy: effect of a self- help manual in a controlled trial.  British Journal of Obstetrics and Gynaecology (98)260-264.

Valbo, W.F., Schioloborg, P (1991)  Smoking Cessation in Pregnancy, mode of intervention and effect.  Acta Obstet Gynecol Scand (70)309-313.

O’Connor, A.M., Davies, B.L., Dulberg, C.S., Buhler, P.L., Nadon, C., McBride, B.H., and Benzie, R.J. (1992)  Effectiveness of a pregnancy smoking cessation program.  Journal of Obstetrics, Gynaecology, and Neonatal Nursing (21)385-392.

Windsor, R. (4th Edition)  A Pregnant Woman’s Guide to Quit Smoking.  Ebsco Media Publisher (1990).

• University of Alabama at Birmingham

The Smoking Cessation and Reduction in Pregnancy Program (SCRIPP) is a culturally sensitive program which systematically educates participants concerning the negative effect of smoking on costs during pregnancy and infant birth weight.  Smoking quit and/or cessation rates registered by SCRIPPs with Medicaid-eligible pregnant smokers resulted in a return of $7-$17 for every dollar invested.  That translates to a national yearly cost savings of $22 million to $59 million if the program were instituted nationally.

Specific Comments Included: A focused program on a major cause of disease.  A strong research focus in a difficult population to address.  Experimental data of high quality for efficacy of intervention with convincing evidence for greater cost effectiveness for treatment.  High public health relevance.  High utility for African-American populations.  Evidence for efficacy of the intervention in changing smoking behavior also has been obtained from implementations in other settings, including public health prenatal clinics throughout the entire state of Alabama.  Cost analyses have documented high levels of savings attributable to these interventions.  This is one of the best documented and most effective health education interventions to be presented in the scientific literature.  Addresses three of the Healthy People 2000 Goals.  Study results are transferable to other populations.  The program was built upon stringent reviews of existing programs and studies.  Data-driven and outcomes-oriented strategic focus.

Reservations Included: Cost savings or projections, and a claims-based study or chart review study should be performed at some point.